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Causes and Risk Factors for a Hernia

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Although some hernias are present at birth, the majority develop later in life. Family history of hernias can predispose you to developing a hernia. In general, conditions that increase pressure within your abdomen contribute to formation of a hernia, including:

• Pregnancy

• Obesity

• History of heavy lifting

• Conditions that predispose you to chronic cough, such as smoking or asthma

• Straining during a bowel movement or urination

• Fluid in the abdominal cavity

Diagnosis

Dr. Cole can usually detect a hernia by physical examination. Sometimes he may want some special imaging studies ordered that are needed confirm the diagnosis.

Treatments

A hernia will not repair itself. It is a defect of the abdominal wall and most hernias require surgery to repair this.  Hernia surgery will depend on the type of hernia that you have.  Dr. Cole will discuss with you the type of repair required and the possible need for mesh.

Risks of Surgery

Although hernia surgery is one of the most commonly performed operations in the United States, as with any surgery, it is associated with risks. These include, but are not limited to, bleeding, infection, scar formation, postoperative pain, damage to the testicles or testicular function, numbness in the groin or the thigh, mesh complications, inability to urinate, bowel or bladder injuries, hernia recurrence, and anesthesia complications. 

After Surgery

Dr. Cole performs most of his surgeries in an outpatient setting.  You will be able to return home after surgery which can help make recovery faster by easing into your daily routine as soon as possible. Depending on your specific type of job, you may be able to return to work 7 days after surgery.  However, if your job requires heavy lifting or heavy physical activity you may not be able to return for several weeks.  You and Dr. Cole can discuss your specific hernia surgery post-operative instructions prior to surgery.

 

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Dr. Cole has performed hundreds of Laparoscopic Cholecystectomies.

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Asymptomatic Hernias

Watchful waiting doesn't pay for asymptomatic inguinal hernias

By: BRUCE JANCIN, ACS Surgery News Digital Network

 APRIL 18, 2013


AT THE ASA ANNUAL MEETING


VITALS

Major finding: Sixty-eight percent of men randomized to nonoperative observation of their asymptomatic or minimally symptomatic inguinal hernia crossed over to surgical repair within 10 years.

Data source: This was an open registry long-term extension of a randomized trial in which 720 men with minimally symptomatic inguinal hernia were assigned to watchful waiting or routine surgical repair.

Disclosures: The sponsor was the Agency for Healthcare Research and Quality. The presenter reported having no conflicts of interest.

INDIANAPOLIS – The luster has suddenly worn off the time-honored strategy of nonoperative watchful waiting in men with minimally symptomatic inguinal hernias.

New evidence indicates the vast majority of men with asymptomatic or minimally symptomatic inguinal hernias will eventually come to surgery. This may not occur until years down the road, when their advanced age may render surgery more arduous.

"Although watchful waiting remains a safe strategy, even on long-term follow-up, patients who present to their physician to have their hernia evaluated, especially if elderly, should be informed that almost certainly they will come to surgery eventually ... The logical assumption is that watchful waiting is not an effective strategy, as with time almost all men cross over," Dr. Robert J. Fitzgibbons Jr. explained at the annual meeting of the American Surgical Association.

He presented an extended follow-up of patients enrolled in a landmark randomized multicenter clinical trial, one of only two randomized studies ever done comparing watchful waiting versus routine surgical repair for men with minimally symptomatic inguinal hernia. In the earlier report by Dr. Fitzgibbons and coworkers, watchful waiting was deemed "an acceptable option" because only 23% of patients crossed over to surgery due to increased pain during the first 2 years of follow-up (JAMA 2006;295:285-92).

At the ASA meeting, however, he presented updated 10-year follow-up data on 167 patients from the cohort initially assigned to watchful waiting. The rate of crossover to surgery was 68% by 10 years, with a marked age-based divergence. Patients below age 65 had a 62% crossover rate, while those above that age had a 79% crossover rate, according to Dr. Fitzgibbons, professor of surgery and chief of the division of general surgery at Creighton University, Omaha, Neb.

The good news was that hernia incarceration was a rare event, occurring at a rate of just 0.2% per year over the course of 10 years.

"We as surgeons have been taught for many years that we must repair all our hernias to prevent hernia accidents. Well, only three patients in our whole study developed incarceration, for which they underwent surgery with no mortality," Dr. Fitzgibbons noted. "The risk of a hernia accident should not be considered an indication for surgery. Older studies in the literature which would suggest otherwise can no longer be considered relevant."

He offered a caveat regarding the study findings: Participants were enrolled after they sought medical attention because of their hernias, even though they were asymptomatic or only minimally symptomatic. So the study results are most applicable to men concerned enough about their hernias that they visit a physician for that reason.

"It’s probably not valid to extrapolate the conclusions in this study to the entire population of minimally symptomatic inguinal hernia patients," the surgeon said. "Physicians have been observing elderly patients for years and would be loath to believe a crossover rate this high."

Nevertheless, the results of this study are virtually identical to those of the only other randomized trial of watchful waiting, which was conducted by surgeons at the University of Glasgow. The most recent update from that study showed an estimated crossover rate in the watchful waiting group of 16% at 1 year, 54% at 5 years, and 72% at 7.5 years. As in the American study, the rate of acute incarceration was reassuringly small. The investigators concluded that watchful waiting appears pointless, and they recommended surgical repair for medically fit patients (Br. J. Surg. 2011;98:596-9).

Discussant Dr. Michael E. Zenilman commented that his own approach is to individualize patient management based in large part upon activity level.

"When I see patients who are 80 years old in the office with an asymptomatic hernia, my conversation with them is about what their lifestyle is like. If they’re an active golfer I know that they’re going to end up getting their hernia fixed. If they’re sedentary, sitting at home in retirement, they don’t. So I think the next step in your research project should be to find out what the activity level is of these patients who are getting older and have asymptomatic hernias," said Dr. Zenilman, vice chair and regional director of surgery for the Washington, D.C., region, Johns Hopkins Medicine.

Dr. Fitzgibbons’ trial was funded by the Agency for Healthcare Research and Quality with support from the American College of Surgeons. He reported having no financial conflicts.

 

bjancin@frontlinemedcom.com

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Hernia Surgery Aftercare Instructions

For our patients who have elected to undergo a hernia repair with an On Q Catheter (Pain Buster), please see the following post-operative instructions.

 

As always, should you have any questions, please feel free to contact Dr. Cole at anytime.

 

Immediate post-operative care:

 

  • Bed rest upon arrival at home and throughout the night.
  • Use the restroom as needed.
  • Gentle stair climbing, if necessary.
  • Ice pack over the incision to reduce swelling and discomfort. May use constantly for the next 7-14 days.
  • Medication for pain as prescribed by Dr. Cole, is most effective if taken as discomfort starts to increase rather than waiting for it to become too severe.
  • Dr. Cole may also prescribe a stool softener to alleviate constipation. Drink a lot of fluid. You may also use Milk of Magnesia or your favorite remedy.

 

Days 1 – 3:

 

  • There will be a clear plastic dressing over your incision. This dressing should be removed 3 days after surgery. Once you remove the dressing you will notice a glue-like substance over your incision. No sutures will be seen as they dissolve on their own. After the dressing is removed, gently pull the catheter out (approximately 4-6 inches.) There will be an intermittent black marks at the tip of the catheter. Once the catheter is removed, place a sterile dressing (bandage) over the catheter exit site. You can take a shower (NO BATH) on the fourth post-operative day, 24 hours after the catheter has been removed.
  • After every surgery there will be swelling, which is a normal tissue response.  Bruising may also be seen under the incision and/or extending into the genital region (penis/scrotum or labia). Again, ice will help significantly. A scrotal support or firm underwear may alleviate discomfort.
  • You may sit on a sofa or at your desk, but minimize your activity.
  • No heavy lifting greater than 15 pounds for approximately 6 weeks after surgery.
  • No driving until after your initial post-operative visit (approximately one week.)

 

Days 4 – 30:

 

  • A ridge of firm tissue will develop beneath your incision. This is part of the normal healing process and will resolve over the next few months.
  • Massage with Aloe Vera gel for approximately 3-5 months, 2 – 3 times per day.  This will help to break down the scarring process.
  • Should you develop a fever or the wound becomes very swollen, tender and/or red, contact Dr. Cole immediately.

 

Follow-Up

 

 

  • Please call Dr. Cole the following morning to check-in and make an appointment within 7 – 10 days.
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