Friday, January 20, 2006

After surgery: What to expect. The Wound

Most local changes and appearances are normal after surgery, usually of no concern, and resolve by themselves.

1.) The wound might become firm and raised, a so-called "healing ridge", and is a manifestation of healing under the skin. I compare it to a small hotdog. It does not cause pain, neither is it a result of an implanted mesh. Interestingly, this varies from nothing to exaggerated "mounds". Commonly, only a small healing ridge appears.

2.) A bluish-yellow discoloration locally or in the genital area may appear after 2-3 days, resulting from drops of blood from the surgery filtering up to the skin. Rarely the area appears extensive. All will be fully absorbed by 10-14 days. Patients on aspirin therapy should, if medically allowed, stop a week prior to the operation.

3.) Transient swelling of the scrotum or testicle on the side of the operation is not common but does occassionaly occur, and usually subsides in a few days. Especially, if the hernia was large, the space that is now empty in the scrotum may fill up with fluid, which the body absorbs. Only in unusual cases is needle drainage required. Rarely a firmness persists for several weeks.

Unusual complications:
1.) Developing redness or swelling associated with increased pain, heat, or discharge of fluid from the wound may be an indication of wound infection.
2.) Temperature above 38 degrees C or 100.5 F, ditto.
3.) Swelling of the scrotum associated with pain.

For all concerns, I always advise a phone call to the surgeon.

Keywords: Wound, healing ridge, post-op.

Thursday, January 19, 2006

Tension-free Repairs

Having an operation done under "tension" does not sound good, so who would want one? The answer is nobody. So what used to be and what is now?

The hole in the wall of the groin was traditionally closed using adjacent muscles and structures. The strong threads would gradually pull through the soft muscles and the hole would reappear within a few short years resulting in a "recurrent" hernia. In my residency years the published figure was as high as 30% failure rate.

Surgeons developed techniques to reduce the tension using "relaxing incisions", multiple layers gradually closing the tissues, darning, etc., still using the patient's own tissues. Specialized hernia centers reported excellent results of 98-99% over the long term. But were these statistics achieved by everyone? No.

About 25 years ago, the Lichtenstein Clinic in California publicized great success using a porous, permanent, flat mesh. Larger than the hole, the mesh is attached to the strong tissues on the side and acts as a bridge. The underlying muscles stay in their original place, ergo no "tension".

All surgeons could learn the technique. Recurrence rates fell.

Keywords: Lichtenstein, Shouldice, tension-free, mesh, polypropylene, רשת

Tuesday, January 10, 2006

Infant Hernia in a 40 year-old?

Many children are born with hernias or develop them at very young ages, displaying genetics at work. Not just the face and voice of a child may be similar to his parents, but also many other parts of the body's structure and function as everything is controlled by the genes.

Boys have far more hernias than girls. The testes develop first inside the abdomen and "descends" through a "ring" in the groin muscles to the scrotum as pregnancy progresses, attached to the spermatic duct and its blood vessels. For reasons unknown, an outpouching of the internal lining of the abdomen (peritoneum) sometimes accompanies the testes in its descent, creating an inverted sac shaped like a toy balloon with the mouth-end open to the abdominal cavity. The balloon may be 1-2 inches long, and if the muscles do not close tightly around its base, a crying baby will force a loop of bowel into the sac, voila, a hernia bulge.

Oddly enough, heavy lifting at age 40 might also open up this sac if the muscles had kept it closed all these years.

Keywords: infant hernia, בקע, שבר

Sunday, January 08, 2006

After surgery: What to expect. Showering.

Shower the next day or the day after. The wet gauze gets removed, and no further bandage is needed. Wash the whole area with soap. The tapes on the skin wound (steri-strips) do not come off with water, and will be removed them at the next visit.

After surgery: What to expect. Pain?

Some people have very little pain after surgery and you might be one of them. The norm is to have pain, but the degree is variable and not related to the size either of the hernia or the patient. In my practice, local anesthesia in the area of the wound is universal, including a drug which may last several hours. Whereas the traditional hospital procedure was to call the nurse for an injection, the new approach is to put the patient in charge and nip the pains "in the bud". Before leaving the surgicenter, two pills are usually given. At home, the patient takes control, taking medicine at intervals of 4-6 hours until the next day, and then as needed. On average, I would say that by the third day, most patients need no medication.

After surgery: What to expect. To bed or not to bed!!!

Should I stay in bed?
The question needs be dissected. Why would one think yes?
1.) I had an operation and now I am sick. Therefore, I stay in bed.
2.) While lying still in bed, I feel no pain. It starts when I try to sit or stand. Therefore, I stay in bed.
3.) When I move, it hurts and I'm afraid to damage the operation. Therefore, I stay in bed.

Bed rest used to be a part of surgical orders. Sixty years ago, our aunts were left in bed up to 11 days after giving birth. Twenty years ago in Israel, seven day hospitalization was the norm following groin hernia surgery, allowing as much bedrest as possible.

The evils of bedrest are now clearer: poor blood circulation in the veins of the leg by loss of the pump mechanism of the leg muscles leads to clot formation. Clots can cause DVT, a blockage of the vein flow with pain and swelling, and raise the spectre of a runaway clot to the lungs called a pulmonary embolus. Muscle tone decreases rapidly, making it harder to spring back to health afterwards. Back pains can develop from prolonged bed rest that might take a long time to improve.

The day after my hernia surgery 10 years ago, I walked 1-2 kilometers and stairs. The Shouldice Hernia Clinic in Toronto schedules exercise classes the next day, not to mention walking off the operating table to the recovery room. Positive thinking on all levels aids a quicker recovery and has been shown to be true in studies.

The hernia repair will not be damaged by movement even if it hurts. Once in the upright, walking gets easier. The objective is to reach these goals early, and you will see that the pains diminish and disappear.

Thursday, January 05, 2006

How do I prepare for ambulatory hernia surgery?

Groin (inguinal) hernia surgery can and is done for most, but not all hernias or patients, on an ambulatory (day surgery) basis. You arrive at the surgical operating theater on the day of surgery and return home a few hours later. My advice to patients is as follows:

 Shower the night before surgery with regular soap, taking care to wash thoroughly all parts of the body.
 Do not shave the area of the operation. It will be done prior to surgery just the area that is necessary.
 Fasting prior to surgery eliminates unexpected vomiting during or after the operation. Approximately six hours of not eating, and four hours of not drinking clear fluids are the usual recommendations. Clear fluids include water, seltzer, tea or black coffee with sugar, and soft drinks. No milk as this tends to curdle in the stomach and is therefore like a food. Juices are too acidic.
 Arrive at the operating theater about one hour prior to surgery to allow time for registration, meeting the staff, changing clothes, intravenous line, etc.
 Be sure to bring with you all necessary papers. This might include insurance carrier authorizations, blood tests, electrocardiogram (e.k.g.), and x-rays, if ordered.
 Valuables should not be brought.
 A family member or friend should be available to accompany you home, and someone other than yourself should drive the car.
 Have medication for pain control available at home. I usually give a prescription at the initial visit and discuss how to take the medicine after the operation.

Keywords: ambulatory, outpatient, day surgery, hernia, ניתוחים, בקע, שבר, הרניה.

Sunday, January 01, 2006

What is a hernia?

Let's define: A hernia is a protrusion (bulging) through a defect (a hole) in the usually strong "envelope" of body tissues enclosing the abdomen, the area of the body between the ribs and the groin creases of the legs. Muscles have a tough outer layer called "fascia" in medical terminology. If small, the bulge might be seen only intermittently, and can be quite distressing. An emergency results if too much bowel or fat suddenly gets caught and cannot by itself return (Incarceration). A doctor can often push it back in. If not, an emergency operation is done to avoid irreversible damage to the intestine (Strangulation), which occurs after several hours of incarceration.

Is there always a hole?:

Sometimes there is no hole, per se, but just a weakness of the muscles and fascia, also resulting in a bulge. This is quite common in the middle of the abdomen (Diastasis Recti) and can be seen when one lies flat on a bed and raises his head or both legs while holding them straight, thus tightening the abdominal muscles. Unless very large, this hardly bothers the person and does not need to be fixed other than for cosmetic reasons. Interestingly, Diastasis Recti can also be found in men, implying a genetic tendency, although women after childbirth predominate.

Keywords: Hernia, diastasis recti, הרניה