Rx for readers: Difficult operations

The decision whether to operate needs to be made by the patient together with the surgeon.

Gaza pills AP for gallery (photo credit: Associated Press)
Gaza pills AP for gallery
(photo credit: Associated Press)
I am a middle-aged man. I had an operation 16 months ago for bilateral inguinal hernia, with mesh inserted. Shortly before that operation, an ultrasound investigation showed an umbilical hernia, but upon examining me, the surgeon said he did not find such a hernia and thus would not operate on it. The operation was open, as requested by my urologist, because he thought there was the possibility that I may need to have my prostate removed in the future.

A few days ago, an ultrasound scan discovered three hernias, including the old umbilical one and two inguinal hernias, which the radiologist told me are internal, as opposed to the ones that were repaired. Another senior surgeon I consulted about the recent ultrasound diagnosis did indeed find the three hernias by clinical examination. He is not in a hurry to operate, and he in fact asked me to lift objects, as well as my small grandchildren, and to report back to him in a month as to whether the exertion was accompanied by pain.

When I lift something and feel pain only eight hours later, is this a direct result of the exertion? In my case, the former inguinal hernias were not painful, while one of the “new” ones is mildly so, and the umbilical hernia causes pain, but only rarely. The new surgeon has informed me that a second hernia operation at the same spot is normally done the other way; that is, if the original was an open operation, then the second one will be laparoscopic, and vice versa. He also said that to do an open operation after a previous open operation is very difficult. But I understand that a prostatectomy after a laparoscopic hernia operation is also very difficult, if not impossible. So how can I trade off the two difficult operations?

Could it be there is something about my tissues that makes it likely that any hernia that I would correct would only open again after a short time or is there something about the operating technique that might cause this to happen? Finally, would I be best not undergoing a hernia operation in the near future?

I.J., Givat Shmuel
Dr. Yaakov Ulano, a leading hernia surgeon and assistant director of the surgery department at Netanya’s Laniado Medical Center and head of a private clinic in Bnei Brak, replies:
Postoperative wounds can cause pain on exertion, regardless of whether the repair was or was not successful. With time, the pains usual lessen in intensity and frequency. I myself still feel some pains after heavy exertion some 16 years after my hernia surgery. However, most people forget they ever had an operation.
Open prostatectomy surgery after laparoscopic hernia repair may or may not be feasible depending on the local reaction to the mesh that is inserted to strengthen the tissue. There are usually other ways to deal with enlarged prostates not requiring the return to that operative site. The main problem is if a radical prostatectomy is needed for a malignancy, which fortunately is a much rarer occurrence.
Surgeons are aware of this problem and try to minimize or avoid the dissection too close to the bladder, trim the mesh in that area, or use lightweight meshes. The speed at which patients want to return to work after laparoscopic hernia repair motivates the use of this technique. You may have a genetic weakness of the tissues – something that is more common after the age of 45 and even more so in smokers. The use of mesh strengthens the repair and should prevent future hernias, so you really should have no need to worry about recurrences.
The operating technique can and does influence the recurrence rate. It should be noted that many surgeons, including myself, rarely or never refer patients for an ultrasound scan. This is because the radiologist may “see” something that may have no significance whatsoever and should not be the basis for deciding on an operation. That the second surgeon detected the new hernias is more significant. Many of these findings need not require the patient to have a new operation. The decision whether to operate needs to be made by the patient together with the surgeon.
Rx for Readers welcomes queries from readers about medical problems. Experts will answer those we find most interesting. Write Rx for Readers, The Jerusalem Post, POB 81, Jerusalem 91000, fax your question to Judy Siegel-Itzkovich at (02) 538-9527, or e-mail it to jsiegel@jpost.com.