drtowfigh
Forum Replies Created
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Parastomal hernia
Please see your primary doctor, gastroenterologist, or surgeon. These symptoms are suggestive of an intestinal blockage and a physician needs to evaluate him on an urgent basis.
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Could be Worse
Does not affect a tummy tuck
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Hernia or Psoas?
Correct.
Not all hernias cause pain with lifting, coughing, getting out of a car. You have to look at the whole spectrum of symptoms that it presents.
That said, the best is to be seen and evaluated in person to really know what is your diagnosis. The examination is very important as well.
I hope you can get help at the Shouldice Clinic, but if you cannot, please do revert back. I and others in the US are eager to give women such as yourself help in diagnosing your pain, even if it is not a hernia. -
inguinal hernia/recurrent hernia using desarda
Perhaps you can provide more about your story.
Why do you feel you had a botched hysterectomy? How did you have two hysterectomies? How are the hernias related to your hysterectomy?
Did your surgeons lead you to believe that your groin lump was from a hip labral tear or a gynecologic problem?
In general, for inguinal hernias, women are more prone to chronic pain related to mesh repairs than men. That may not be true for you or any specific patient, and so the surgeon should make their best determination as to what is the best repair. Among mesh repairs, laparoscopic mesh repair has a much much lower risk of mesh-related chronic pain than an open mesh repair. And if you choose to have a laparoscopic repair, then it should be done by a specialist who performs laparoscopic hernias routinely and has excellent outcomes.
With regard to mesh vs non-mesh repair, the non-mesh repair is preferable especially among thin young women. If you are overweight, are older, or have a lot of risk factors for hernia recurrence, I usually do not recommend non-mesh repair, as the risk of hernia recurrence is a bit high and the risk of mesh-related pain with laparoscopic repair is so low, relatively speaking.
The Desarda technique is a revival of an old technique that was abandoned in the 1950’s and 1960’s because the recurrence rate was too high. The best validated tissue repairs for women are the Shouldice technique, Bassini technique, and in some cases the Marcy repair. Like laparoscopy, tissue non-mesh repairs are best performed by surgeons who are versatile in doing them. In today’s world, that usually means the surgeon is either older or they are hernia specialists who are versatile in a wide variety of techniques. The tissue repairs are not widely taught anymore in normal general surgery training.
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Hernia or Psoas?
The normal Inguinal canal is a diagonal tunnel that travels through multiple layers of muscle. In women, that tunnel is large enough to accommodate the round ligament, the size of a noodle, and the genital nerve, the size of a thread. So, it’s a relatively narrow tunnel. If it dilates up due to weakened muscles or abdominal pressure, fat, and rarely intestine, can creep into it. In the early stages, the tunnel remains diagonal or angled, and it is hard for contents to easily travel through. If a piece of fat gets stuck in it, the pressure causes pain. Exercises such as Pilates can provide muscle support to reduce the gaping of the tunnel and reduce chances of the hole getting bigger. At later stages, the muscles surroinding and supporting the tunnel gape open, the tunnel is no longer a diagonal narrow tunnel, rather a wide direct tube or hole that allows for contents to go in and out. That is when a bulge is noticeable on examination. Prior to that, imaging is helpful to detect a hernia.
I usually do not offer laparoscopic exploration prior to imaging as there are instances where non-hernia diagnoses arise, such as hip labral tears, sacroiliitis, tumors, which may explain the groin pain. Also, once the hernia diagnosis is made, the discussion about the type of hernia repair is an important discussion to be had. Laparoscopic repair may not be the right choice for each patient. So preoperative planning is very important in order to tailor the repair to the needs of each patient. -
Thank You!!
I’m not sure where people got the misconception that women don’t get hernias, because they do. They just don’t get it as often as men. The ratio is quoted to be about 7:1 male:female ratio. Most of these are regular hernias, not femoral hernias. Femoral hernias are rare, even for women. However, women are more likely to get them, by a factor of 10. Does that make sense?
My personal bias is that th 7:1 ratio is probably underestimating the true number of women with hernias. There are probably many-fold women that have hernias that are undiagnosed or misdiagnosed. You and others may be perfect examples of such.
In any case, the likelihood that there is intestine in most hernias is low, especially small ones. It is usually fat. Obesity has not yet been linked with development of groin hernias. Nor has rapid weight loss. Exercise and muscle strengthening is protective against hernia development. Perhaps the weight loss has allowed you to notice the bulge better. That is a plus, because it makes the diagnosis easier.
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Hernia or Psoas?
Wow, I wish all my patients came with such thorough and insightful histories. Thank you for that!
Well, you hit every single point that I usually tackle during the detailed hernia questionnaire that we go through during consultation (you can find a copy of it on my website if you don’t believe me!). You pretty much said “Yes” to everything on our list: pain at the groin that radiates up and around to the back and down the upper thigh, worse with sitting and standing, best with lying flat, associated nausea and bloating, notably worse with bull bladder and pain lingers after a bowel movement. Exercise does not make it worse, as most exercises do not cause an increase in abdominal pressure.
You do have a risk factor of hernia: family history. And we have noticed that a female link is stronger than a male link.
Ultrasounds for hernias must be done as a dynamic study. That means, standing, coughing, walking around. It should never be done while lying flat. That would likely result in a “false negative” study, that is, a report that says there is no hernia, when in fact there is one. In our study, we found that for small hernias, 50% of the time, the ultrasound was falsely negative. It is possible that this is because of technique more than the ultrasound quality itself.
If there is no actual bulge at your groin area, but your symptoms are suggestive of an inguinal hernia, then you fall into the category of an occult or hidden hernia. This is most likely to be found among women. In these circumstances, I recommend an ultrasound, and if that is not diagnostic, then a dynamic MRI. We have noted in our studies that the dynamic portion of the MRI pelvis is actually highly important in helping diagnose small occult hernias. A flat MRI pelvis may be adequate in many situations.
So, based on this assessment, which, granted, is based on your story, without any review of your films or any examination…
I do recommend that you seek a hernia specialist for your situation. You can start with a general surgeon who has interest in hernias, but most are not in tune with the concept of occult hernias among women, and so you may need to be patient and seek another consultant if the first one does not provide you with an answer to help rid you of your pain.
I am not familiar with specialists in Alberta. You can first try the Americas Hernia Society website (www.americanherniasociety.org) to see if any members live in your Province. The Shouldice Clinic in Ontario is another option, and I am in contact with them to discuss the concept of occult hernias among women.
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Could this be a hidden hernia ?
Ok, good luck.
Dr. Ramshaw can at the least confirm your diagnosis and point you in the right direction. Good luck with that and thanks for keeping us in the loop.
CPR involves a lot of ab-work. I can imagine it can definitely irritate a hernia.
Your CT did show a hernia of the right groin, and MRI confirmed it. The repeat CT scan you had recently should show the same. The reading may not have focused on it, which is not uncommon, unfortunately, as hernias are often not read or misread. This is the reason that I insist on reading my own images and do not rely on reports alone. We are trying to publish our results on exactly this problem, as we have noted that the majority of CT scans (70-80%) are either misread about hernias or no hernia is commented on at all, despite the fact that there is one on the image. Radiology is truly more of an art than a science.
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Maybe a Hernia?
Yes. Definitely can be a hernia. The area of your pain (to the side of the pubic bone, but not yet at the level of the hip bone), the type of pain you have (feel it in the labia, the leg, when coughing, with vomiting), noticing a slight bulge in the area… all are pretty classic for a hernia as noted in women. It is possible you may have a small one on the opposite side, too, based on your symptoms.
I do not recommend an MRI for all patients. It should be reserved for patients with prior hernia repairs and with those who have occult hernias (i.e., hernias that are not able to be found on examination but there is high clinical suspicion for them). In your situation, you are noting a slight bulge already. A dynamic hernia musculoskeletal ultrasound alone should be adequate, and if performed correctly should confirm the hernia diagnosis. In fact, if the examination is diagnostic of a hernia, no imaging is necessary. This is a very important point.
So, please seek consultation with a general surgeon who has interest and experience in hernias. A list may be found on the Americas Hernia Society webpage (www.americanherniasociety.org), by state, based on their membership with the AHS.Lastly, if you indeed do have a hernia, and you plan on having an operation such as the VBLOC, then it would be up to your surgeon to determine if he/she would like to perform both operations at the same time. In some situations, the surgeon may want to ask a second surgeon to perform the hernia repair, if he/she does not routinely perform laparoscopic inguinal hernia repairs. I personally do not believe there is a contraindication to performing both procedures at the same time. They are both “clean” operations. However, I would defer to the preference of your surgeon to determine the plan of care.
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Are these symptoms of an “occult female hernia?
Try Dr David Chen at UCLA.
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Feeling frustrated
Sometimes there are small “epigastric hernias” in the middle between the belly button and the lower rib cage area. A piece of fat can get trapped there and cause pain with certain crunches. That is the only thing I can think of that may be causing your pain that would be hernia-related. An ultrasound or CT scan should identify it. Surgery will cure it.
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Feeling frustrated
Where exactly is the cramp? Do you have associated bulge, nausea, radiation of the pain elsewhere? Any other activities cause the pain, such as coughing, bending, lifting?
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Are these symptoms of an “occult female hernia?
Sounds very likely to be a hernia. Other options may be hip-related issues, but your symptoms certainly are more consistent with an inguinal hernia.
I am happy to see you in consultation. Your MRI needs to be Re-read to make it is correctly interpreted. -
Hernia Surgery Risks in an 88yr old Woman
It’s too early to say. If it’s better with walking then that’s a good sign. The area is tighter than she was so it’s normal to feel pain when engaging the muscles such as to get up from a chair or out of bed.
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Are these symptoms of an “occult female hernia?
Absolutely can be signs for an occult hernia.
Do you have pain with coughing, laughing, getting out of bed or car, prolonged sitting, prolonged standing? Is it worse at the end of the day, better when lying flat? Worse with your period? Painful with sexual intercourse? Do you feel a lump or swelling at the groin area or above the crease? Does the pain radiate down the top of your thigh, around to your hip, to your back, up to your belly, or into your vagina?
Ice helps.
What did your hernia surgeon say? Did the ultrasound or MRI pelvis remark about the hernia area at all?
Go to the American Hernia Society web page or let me know which part of town you live so we can help you find a specialist who can evaluate you. -
Pre-Surgery Diagnosis Needed?
The area and symptoms may be due to a Spigelian or interstitial inguinal hernia. Hard to believe it was missed on CT but it’s been known to happen. A Valsalva image (CT or MRI) helps view small hernias best.
You can have your images re-read by a local radiologist as a consult or I am happy to review them. Ileostomy seems extreme for your problem and based on your GI workup is low likely to resolve your symptoms. Upon laparoscopy, the peritoneum needs to be taken down to be completely sure there is no hernia. I assume that was not done with your last laparoscopy. And during loop ileostomy depending on the technique they may not do anything more than a right lower quadrant incision.
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Hernia Surgery Risks in an 88yr old Woman
Surgical site infection is always a concern. I recommend showering with soap or antibacterial agent (Hibiclens) the night before and the day of surgery.
Make sure she does not have a uronary infection or other infection at the time of surgery.
Blood clots in the legs are dangerous and risky after surgery. Walking a lot before and after surgery will help reduce that.
Do not shave the groin area yourself. Leave it up to the surgeon to do it the same day of surgery.
Eat well. High protein diets tend to offer best healing nutrition. Also, can take extra Vitamin C and Zinc. That also helps with healing.
Take Arnica 12c three times a day starting a few days prior to surgery and continue after surgery. You will notice less bruising, swelling and pain. Let your surgeon know.Good luck!
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What to tell the ultra sound technician
That makes me so happy! 😛 😆
Please promote HerniaTalk to your friends and also your surgeon and their staff.
Great success story. -
Pre-Surgery Diagnosis Needed?
Intestinal problems can be very complicated to diagnose. There are a wide variety of causes of bloating including motility disorders, hypothyroidism, narcotics use, small intestinal bacterial overgrowth, etc. In addition, hernias can cause symptoms of bloating, nausea, abdominal pain.
Typically, the bloating, pain and nausea are due to direct involvement of intestine with the hernia. In my practice, I have also regularly seen patients without intestinal involvement of their hernia (ie, hernia with fat content only) who have bloating, nausea and this resolved after the hernia repair. In analyzing these, it seems that the nausea and bloating are the body’s reaction to the pain from the hernia.
A CT is adequate for evaluation of the abdomen. MRI is more useful for the pelvis. CT with Valsalva (beardown) would be preferable. A careful review of the CT would show the umbilical belly button hernia and any Spigelian hernia. Spigelian hernias typically occur two finger breadths below the level of the belly button and on the edge of the rectus muscle (the abs or six-pack). It sounds like you are describing pain at the same area.
I do not know what studies have been done to evaluate your GI tract. From what you have posted, there is no major motility disorder of the colon, which would be the only reason to perform an ileostomy, and even then that is a drastic procedure and still does not address the colon motility, which remains in situ.
Umbilical hernias may present with pain at their periphery, usually a couple of finger-breadths to the side, but not lower in the abdomen. You may have a simple inguinal hernia. That is much more common than a Soigelian hernia. In such a case, a dynamic MRI pelvis would be helpful. Also, as I explained above, your symptoms may be associated with an inguinal hernia. I have seen it in my practice dozens of times.
Do you notice any bulging or protrusion in the area? Is any of your nausea, bloating, pain associated with activity? Intercourse? Menses? Sitting? Coughing?
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Unusual Abdominal Injury
It’s possible dry needling in the acute stage (6days) may have exacerbated your problem. I am not an expert in this method but typically this method should be reserved until after the acute phase.
Yes, 6 weeks after injury.
6-½ months is a long time, unless you have not allowed it to fully heal, ie no full rest. Typically, for muscle tears, we recommend 3-6 months of complete rest.
Yes, CT or MRI can show this as can ultrasound.