Surgery VS Watchful Waiting

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hello,

I’ve been debating for many months whether or not to have surgery for small, hidden, inguinal hernia. The pain is intermittent (i.e. a few days of significant discomfort followed a week or two of almost no pain). The pain is a pinching, pulling aching from the pubic bone to the hip. Sports and activity do not generally provoke pain so my life is not really limited per se – I’m just chronically uncomfortable. On bad days, I feel lousy. I lose my mojo and feel convinced that surgery is the right thing. But then it passes and I think (particularly after reading statistics and stories…) that I would be foolish to risk my relatively OK quality of life.

With hopes you can help me (and others) weigh my symptoms versus risk of post-operative pain, I have a few more questions:

– According to the Manual of Groin Pain, “preoperative groin pain predicts an increased likelihood of postoperative chronic groin pain”. Can anyone clarify why this is so? Is it because groin pain is more often caused by something other than the hernia (as was told to me by one surgeon). As groin pain is a common symptom of hernia – and one of the main reasons for risking surgery – it’s something of a conundrum!

– Is intermittent pain typical of hernia? If so, would you say this is because pain is felt when the piece of tissue is lodged in the canal causing pressure – and relieved when it is not?

– Is it true that small hernias are at greater risk of strangulation than big ones?

– Is it possible that a hernia will become less painful when the hole gets bigger thus relieving some pressure?

– Would nerve blocks be a viable alternative to surgery in some cases (this has been suggested by my GP).

– And finally, some doctors are of the opinion that ALL groin hernias in women should be fixed. Do the doctors on this forum have thoughts on this? Dr. Towfigh refers to the Veteran’s study in the New England Journal of Medicine in which many waited with no complications. Am I correct in assuming the subjects were all men? Can small hernias in women be safely watched – and possibly never fixed? (BTW, I am a healthy 56 year old female).

Many thanks!

[pszotek]

Surgery VS Watchful Waiting

Tilbis,

Thanks for the very thoughtful and researched post. I will try to do my best to answer some of your questions and I think once we all weight in you should have a nice overall sense of a small consensus.
1. Pre-Op = Post-Op: I don’s know that there is scientific evidence one way or the other. I think that sometimes its because the original pain was from other sources and I think sometimes that the pain is caused by the patients anatomy/neurogenic in nature and not necessarily the hernia regardless of size.

2. Intermittent is typical – Many folks say the pressure and pain gets worse with standing for long hours. Over the say the muscles get tired and become weaker so its a combination of the hernia pushing out and the overall increased stretch of the abdominal wall secondary to fatigue from standing long periods in an already weak tissue.

3. Yes and no on the small hernias – Very small less than 1.5cm or so are extremely rare to have bowel incarceration and strangulation. ” Small hernia’s in the 2-6cm range do demonstrate an increased risk of incarceration and strangulation. Large and very large hernias rarely incarcerate and strangulate in my experience.

4. Yes the hernia can become less painful over time but the pressure is likely to remain the same or get worse.

5. Nerve blocks – Yes and No – Short term they are great but it is a lot of work to get them setup and also a lot of work to maintain the injections every couple of days for long periods of time.

6. Its hard to answer the question with such a broad range of possibilities ( true inguinal hernia or incision hernia from c-Section, etc?) I will say that I do not treat my female patients any different than men and watchful waiting does not have any different effects on women as on men. I believe subjects in that study were indeed men.

Hope that helps a little bit and hope to be of service in the future. Dr. Szotek

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Surgery VS Watchful Waiting

Thank you, Dr. Szotek for the thorough response. A few follow up questions and comments:

1. When you refer to the “patient’s anatomy/neurogenic in nature” are you meaning that there are sort of ‘phantom pain pathways’ caused by the hernia – that can remain after the hernia is fixed?

2. I certainly understand and feel the effects of standing for hours but by ‘intermittent’, I was meaning a few weeks of discomfort followed by a few weeks of almost no pain. I’m trying to understand the mechanics of this! I do pilates and yoga and wonder if there is any correlation between exercise and degree of pain – or if it’s more random. This may be a dumb question but if pain is caused by tissue in the hole (?), is it possible that exercise can keep it out of the hole?

3. Does strangulation only involve bowel (or maybe bladder?) – or can a piece of fat dangerously strangulate? When diagnosed 8 months ago, my hernia was only 6mm – not sure what it is now. One surgeon I met with believes that a hernia that size (and with no bulge) barely qualifies as a hernia and that performing surgery on me would be almost unethical. Elsewhere I read that ALL hernias in women should be operated on. Do you agree with this and, if so, is it because it’s possible that femoral hernias (which are more dangerous) can be mistaken for inguinal hernias?

Thanks!

[drtowfigh]

Surgery VS Watchful Waiting

Wow. So many great questions.

Scientifically, we don’t have perfect answers for everything you are asking.
Some comments limited to inguinal hernias in particular:

– all hernias in women do NOT need to be repaired. Femoral hernias are the exception. Femoral hernias should be repaired if they are diagnosed, as they are at highest risk of strangulation. The timing of that repair is unclear.

– hernias that are symptomatic should be considered for surgical repair. The size is not a determinant of repair. For sure there are super small hernias that are very symptomatic, and the reverse may also be true. I routinely repair very symptomatic often debilitating hernias that are very small. They are called occult hernias. A lot of surgeons don’t agree with me. I presented my data for these naysayers: 87% cure.

– nerve blocks do not treat hernias nor their pain. In fact, in most cases, it may increase the pain. It’s a diagnostic tool

– exercise can help reduce symptoms from the hernia and/or reduce their size.

– strangulation is most risky with Bowel. Bladder does not strangulate. Rarely it can incarcerate. Fat can strangulate

– almost al the data we have about hernia outcomes is with men. A few of us are adding women to the pot.

In short, hernia repair, as with any elective surgery, is a personal decision. You must weigh its risks and benefits. If performed by an expert, the risks should be less. This is especially true for women

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Surgery VS Watchful Waiting

Thanks for the helpful info! There are still two points I’m curious/confused about:

– Would you say that intermittent pain (few weeks on, few weeks off) is typical of (hidden) inguinal hernia? If so, would you guess that pain is triggered when tissue is in the canal, and relieved when it is not? (I understand there is no way to heal the hernia but wondering if targeted exercise might actually keep the pesky tissue at bay!)

– regarding pre-op pain predicting stronger likelihood of post-op chronic pain (according to Manual of Groin Pain): I understand that in some cases this is because pain is caused by something other than the hernia. If, however, my pain IS due to hernia (difficult to prove, I know), would my chances of post-op pain still be greater than those who went into surgery with no pain? If so, can this be explained?

As mentioned at the top of this thread, pain/discomfort is the main reason many of us would risk surgery. If, however, the odds of ending up with symptoms that are the same or worse (even in expert hands), this is something we need to consider carefully.

[drtowfigh]

Surgery VS Watchful Waiting

First: it is much more likely that you–or anyone–have improvement than chronic pain after hernia repair–even those with pain preoperatively.

At this point, we don’t have a good way to know prior to surgery if any particular person will do well. Dr Ramshaw is dedicating his career to finding this out.

To answer your two questions: we don’t know. Medicine is an Inexact science and a bit of art. We just don’t know enough to be able to answer you and therefore perfectly tailor your exercise to be the best for your situation. Yes, hernias can have intermittent pain. Why? We don’t know.

[MO]

Surgery VS Watchful Waiting

I want watchful waiting for a left indirect omental scrotal hernia. The amount of omental fat in scrotum looks like a third testicle. No pain. Reducible.
What is the risk of strangulation?

[MO]

Surgery VS Watchful Waiting

I do not need to know exact risk, just if watchful waiting is reasonable.

[pszotek]

Surgery VS Watchful Waiting

MO

Difficult to quote for sure but your particular hernia is on the higher end of the risk spectrum than a non-incarcerated, reducible hernia as I am assuming by your post that you cannot push it back in? Some data will suggest the risk in the range of 2% / year that you watch it that it will require surgery on an urgent/emergent basis. In my opinion your would be higher but unable to predict to my knowledge.

Thanks
Dr. Szotek

[MO]

Surgery VS Watchful Waiting

It is partially reducible when lying down, at least 2/3 goes back in.

[MO]

Surgery VS Watchful Waiting

Are there published guidelines that are credible to most surgeons?

[drtowfigh]

Surgery VS Watchful Waiting

yes.
read:
1. http://jama.jamanetwork.com/article.aspx?articleid=202212&resultclick=1
It shows 0.18% per year risk of incarceration with watchful waiting.

2. http://link.springer.com/article/10.1007/s10029-009-0529-7
It outlines evidence-based treatment of inguinal hernias

[cm-rom]

There are no similar studies with the same accuracy (at least I wasn’t able to find one) on ventral post incisional (para umbilical/epigastric) for watchful waiting emergency admission prognosis. What is your perspective on this? Would you apply a “no go” management (in case of no pain/no defect advance/no cosmetic reasons) for ventral post incisional hernias? Does the size of the defect matter in this case?

[drtowfigh]

There have been studies in incisional, ventral, and umbilical hernias and watchful waiting. The consensus is that, though safe to watch asymptomatic/minimally symptomatic repairs, patients with surgical repair have significantly improved quality of life and less overall pain

[saro]

Thank you for dealing with the preliminary node of all the hernias. Frankly, it turns out that strangulation is a rare occurrence, but I’m not a doctor, so I will only say that I am not very concerned about strangulation myself, but I might be denied the facts.
I will also say that I have been from three years with an inguinal hernia, held by a watchful attitude of life, and some appropriate exercise: when I forget the hernia and make an effort, or if I do a wrong exercise, I remain in trouble for days , Even weeks, with swelling. Growth of the hinged door occurred only in the third year, perhaps due to an effort, so now the hernia, without bands, tends to position itself in the groin. In the past, however, it remains in place, and then it seems to have nothing, because it does not bother …. My terror, being a man, is that it slips into the scrotum, as it is an indirect hernia. Someone has experience or suggestions

[drtowfigh]

Saro,

A scrotal inguinal hernia may not necessarily have any higher risk of strangulation than a non-scrotal hernia. In fact, some may argue the risk is lower, as the hole is actually wider.

[iconoclast]

quote drtowfigh:

Surgery VS Watchful Waiting

– exercise can help reduce symptoms from the hernia and/or reduce their size.

Can you be specific with suggestions of exercises?

I find just standing to be the worst for causing symptoms. Walking (30 minutes or less) has very little effect, possibly due to core muscles activated when walking? Lifting anything heavier than 15lbs will produce a bulge, which can be massaged back in.

If I’m able to do some exercises to not only strengthen the area, but put off the need for surgery awhile, allowing the ability to work, that’s a significant benefit.

[iconoclast]

Bump, drtowfigh?

[drtowfigh]

The recommendations for exercise are based on low impact exercises that focus on core strengthening and that also do not increase abdominal pressure. There is a bit of research done on this. Most exercises are considered safe and/or encouraged. These can include safely performed weight lifting, situps, Yoga, Pilates, cycling. Jumping and squats are considered to increase the abdominal pressure, so I recommend no Cross-Fit type exercises.

[iconoclast]

Thank you.

Right now, the two things which tend to produce the most pressure/pain/bulge: just standing for a length of time sometimes it’s 15 minutes other times a bit longer. Carry or lifting weight (over 15lbs – which is nothing when I used to train). Hiking up and down hills tends to be fine for 25 minutes, after that hiking can produce similar to just standing. I don’t know if maybe core muscles activate when walking/hiking?

btw – I used do serious core training, I am quite lean right now, I’d guess about 12% body fat.

[saro]

As I have read some specialists prefer to recommend interventions with minimal symptomatic hernia, others suggest repair only when the hernia obstructs daily activities.

I return to the initial question: on a hernia that does not give pain
I find it amazing that the behavior of inguinal hernia is sometimes really ‘capricious’
Sometimes the hernia faces outwardly into the inguinal canal, forming a ‘sack’. It is amazing that the same hernia can then be reduced to a ‘tip’, that is, to the initial sketch, following an orderly and satisfying day in which some factors are balanced: mind-body balance (as it may have when walking ” doing other activities and therefore with the mind involved in the activities), a manifestation of moods, adequate nutrition .. I think there is a connection between the various functions (digestive, mechanical-locomotor, nervous, hormonal) that condition the ability muscle on the site by determining its tension or laxity
I’ve been tracking the bizarre behavior of my hernia for years, but I can not explain it well, and I can not explain what’s happening

[drtowfigh]

Capricious is an excellent term. And everyone is different in how and when they get symptoms.

[saro]

quote drtowfigh:

Capricious is an excellent term. And everyone is different in how and when they get symptoms.

You have claimed that magnitude is not a decisive factor in recommending surgery. Do I guess this has limits (when the hernia develops too much, could it damage the nearby organs?)
can we consider symptomatic or little syntomatic a hernia that is painless? perhaps reducible, perhaps even of average magnitude?
A similar hernia, which allows the daily vital functions to be carried out, could be handled without harm?

[drtowfigh]

A huge hernia by itself may not necessarily damage organs.

[drkang]

Real watchful waiting should have strict conditions.
That is, it should be carried out under the condition that operation would be performed if the size increases over certain level, some pain appears, the frequency of pain increases, or other discomfort occurs and so on.
But many people are just waiting until the condition becomes very serious.
It is not ‘watchful waiting’ but just ‘neglecting’

As you know, herniated bowel or contents could be incarcerated/strangulated though it happens rarely.
But that is not the only problem.
The bigger the hernia is, the more difficult the repair is.
And the recurrence and complication after repair might also be increased.

So I think the sooner the better.
I personally recommend you to get hernia repaired if it is bigger than a cherry even though it doesn’t hurt at all.

I understand the possible mesh complication makes many people to hesitate.
And I know it’s difficult to find a surgeon who does tissue repair properly with low recurrence and less complication.
That is a pitiful dillema.

But I don’t think the so-called ‘hidden hernia’ should be repaired.
‘Hidden hernia’ is not a real hernia as dragon is not a real animal.
I think hidden hernia issue appeared after the inguinal hernia began to be repaired laparoscopically, because laparoscopically the operative procedures for real hernia and so called ‘hidden hernia’ are the same.
Actually that for hidden hernia(in other word, absence of real hernia)) is much more simple.
They just put the large mesh around inguinal area.

I hope that everyone would be able to have a hernia operation without worrying about it soon.

[ajm222]

quote drkang:

Real watchful waiting should have strict conditions.
That is, it should be carried out under the condition that operation would be performed if the size increases over certain level, some pain appears, the frequency of pain increases, or other discomfort occurs and so on.
But many people are just waiting until the condition becomes very serious.
It is not ‘watchful waiting’ but just ‘neglecting’

As you know, herniated bowel or contents could be incarcerated/strangulated though it happens rarely.
But that is not the only problem.
The bigger the hernia is, the more difficult the repair is.
And the recurrence and complication after repair might also be increased.

So I think the sooner the better.
I personally recommend you to get hernia repaired if it is bigger than a cherry even though it doesn’t hurt at all.

I understand the possible mesh complication makes many people to hesitate.
And I know it’s difficult to find a surgeon who does tissue repair properly with low recurrence and less complication.
That is a pitiful dillema.

But I don’t think the so-called ‘hidden hernia’ should be repaired.
‘Hidden hernia’ is not a real hernia as dragon is not a real animal.
I think hidden hernia issue appeared after the inguinal hernia began to be repaired laparoscopically, because laparoscopically the operative procedures for real hernia and so called ‘hidden hernia’ are the same.
Actually that for hidden hernia(in other word, absence of real hernia)) is much more simple.
They just put the large mesh around inguinal area.

I hope that everyone would be able to have a hernia operation without worrying about it soon.

This is good info, thanks. Living in the US, and being somewhat restricted by the way insurance works within each state, most of us are at the mercy of the fact that 99% of hernia repairs seem to be done with mesh. And those that aren’t are probably performed by surgeons who only do a handful of pure tissue repairs a year and only in certain limited circumstances. So it’s basically a matter of when to get the mesh repair. Especially when you have to place a certain amount of trust in your doctors/surgeons and they all say that mesh is still the gold standard and the way to go. That’s what I am trying to decide myself now. I have a small little lump and feel like I should just get it fixed rather than simply wait for it to get worse. It isn’t large and it isn’t painful. But I have no doubt it will get to that point, eventually. I did read that it doesn’t make much difference in terms of success of surgery if you wait, unless it gets quite a bit larger. Maybe because mesh they use covers a large area anyway. I figure I can wait a few weeks or a few months. But I don’t like the idea of waiting longer, even if it isn’t painful. I’m already limiting myself greatly for fear of making things worse. I don’t like living that way. But I also don’t want any chronic pain at all from a surgery that doesn’t go perfectly. As you say, it’s a dilemma.

[saro]

I found a large difference in the volume of the hernia on the same day in relation to a stress event

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

quote drkang:

Real watchful waiting should have strict conditions.
That is, it should be carried out under the condition that operation would be performed if the size increases over certain level, some pain appears, the frequency of pain increases, or other discomfort occurs and so on.
But many people are just waiting until the condition becomes very serious.
It is not ‘watchful waiting’ but just ‘neglecting’

As you know, herniated bowel or contents could be incarcerated/strangulated though it happens rarely.
But that is not the only problem.
The bigger the hernia is, the more difficult the repair is.
And the recurrence and complication after repair might also be increased.

So I think the sooner the better.
I personally recommend you to get hernia repaired if it is bigger than a cherry even though it doesn’t hurt at all.

I understand the possible mesh complication makes many people to hesitate.
And I know it’s difficult to find a surgeon who does tissue repair properly with low recurrence and less complication.
That is a pitiful dillema.

But I don’t think the so-called ‘hidden hernia’ should be repaired.
‘Hidden hernia’ is not a real hernia as dragon is not a real animal.
I think hidden hernia issue appeared after the inguinal hernia began to be repaired laparoscopically, because laparoscopically the operative procedures for real hernia and so called ‘hidden hernia’ are the same.
Actually that for hidden hernia(in other word, absence of real hernia)) is much more simple.
They just put the large mesh around inguinal area.

I hope that everyone would be able to have a hernia operation without worrying about it soon.

Dear Dr. Kang,

I have a few questions regarding your comments on “so-called hidden hernias”:

Do you believe that hidden hernias are the first stages of a ‘real’ hernia? Or are they something else entirely?

I’ve had groin pain for 4 years but no visible or palpable bulge. Two years ago, an ultrasound revealed a small, 6mm indirect inguinal hernia. Is it your opinion that it should not be repaired? If so, is this because open, non-mesh surgery is not possible for hidden hernias – and that you don’t recommend laparoscopic repair with mesh? Or do you believe my pain is likely caused by something else?

Also, do you believe that this hernia will inevitably grow bigger and that a bulge will eventually appear? If so, would it not be better to get it repaired while it is small – particularly as it is symptomatic?

Thank you.

[Chaunce1234]

Just to chime in here as a fellow patient, I have read a working theory that, at least with regard to thin/athletic/fit patients, a “hidden hernia” is often basically the early stages of a regular hernia that hasn’t fully formed the traditional bulge yet, but can either be a small amount of intrabdominal fat lodged into the inguinal or femoral canal which compresses a nerve, or even a tear or disruption in the groin muscle from an injury that compresses on a nerve or indirectly pulls on a nerve by yanking on surrounding muscle fibers. The latter is sometimes referred to as “inguinal disruption” or “sports hernia” and is known to be a painful condition.

Anyway, this is clearly a complex topic.

As for patients who desire a non-mesh repair in the USA, it has to be sought out rather specifically because it is not a common procedure despite there being a clear market demand for it. I have posted a list in some other forum threads before with surgeons in the USA who are known to perform non-mesh repair for anyone interested, for most people they will need to travel, often to another state or region of the country.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Thanks, Chaunce, for your insights. I agree with all you say. The thing I don’t understand is, why are hidden hernias so controversial? Why do so many doctors and surgeons doubt that a small bit of fat lodged in the canal can be painful?

I live in Canada. I’ve consulted with two surgeons in my home town (Calgary) and neither are convinced my pain is caused by a hernia – despite my classic symptoms, family history and an ultrasound report. They are of the opinion that a 6mm ‘hernia’ is little more than a natural gap in the muscle wall. They believe nerve entrapment is a more likely scenario and suggest I try steroid injections.

Without insurance, I can’t afford to pay for surgery in the US. I would be interested in going to the Shouldice Clinic (near Toronto) but they won’t accept you unless a bulge is felt. The reason (according to Dr. Towfigh) is that they believe patients are less likely to have a good outcome (I suspect this means they believe there is a greater likelihood of pain post-surgery). One surgeon I spoke with believes this is because the pre-surgery pain was likely caused by something other than hernia and that the surgery was needless or, worse, caused injury. And this is what scares me. And so I do nothing and live with intermittent moderate pain/discomfort, wondering if I a bulge will appear if I stopped doing pilates…..

[smallhernia]

I was lifting a bed frame four days ago (actually not very heavy at all) when I suddenly felt a pop and sharp epigastric pain. Now the pain comes back with coughing, sneezing and movement. Ultrasound found a 8 mm supraumbilical incisional hernia. There is no visible bulge. I had an abdominoplasty 1 year ago with excellent cosmetic results and I hate to mess it up with surgery. Is there any possibility that the hernia will resolve spontaneously? Would most surgeons watch and wait on this one?

[LeviProcter]

It will not disappear.

It will always be there.

It will increase in size over time (unpredictable rate however).

If asymptomatic leave it alone.

I would not offer an operation if it was asymptomatic and without evidence of intestine in it.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Dr. Procter – would you offer surgery to a 57 year old woman with no bulge but classic groin pain, family history and an ultrasound report showing a very small, indirect inguinal hernia? If so, what sort of surgery would you recommend? If not, would you propose waiting until a bulge appears? Or would you say that it is likely something else like nerve entrapment and recommend steroid injections? Thank you.

[cm-rom]

Dr. Towfigh, thank you for the reply – I am watching your activity with great interest.
The reason I’m constantly scratching my head is: let us presume that you have waited a few years: no pain no drama – the defect of the fascia is relatively small (less than 3mm as indicated by the CT scan) and it stays the same while you avoid jumping high/coughing strongly – what is the probability that anything else but the omentum to fill your hernia sac? Omentum should be smart enough to fill the gap, to avoid the bowel (which is 2-2.5mm for a grown up) to protrude the defect, correct? Is this omentum or the pre-peritoneal fat affected by the abdominal muscles constriction? My understanding is that we are able to travel to the moon but we are partially able to understand how this organ works or how to solve issues related to the peritoneum hurt induced adherences….

[Author]

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