The Shouldice Hospital, Hernias
If It’s Partly Broken Should You Fix It?
by Dr. W. Gifford Jones
February 19, 2006
Do you want to have a body free of imperfections? In an ideal world we would all say “Yes”. But how important is it to be perfect?” A recent report shows that in some surgical operations it’s prudent to live with a slight imperfection.
Several months ago I watched one hernia after another being repaired at Shouldice Hospital in Toronto. This clinic has developed an international reputation for doing one thing very well. It’s the old story that practice makes perfect whether you’re a surgeon or a plumber.
During the visit Dr. Casim Degani and his colleague Dr. Michael Alexander told me about a six million dollar study being conducted to determine if all hernias need to be repaired. This report, just released in the Journal of the American Medical Association, stresses that some hernias can be safely left alone.
Researchers reached this conclusion after following 720 men with inguinal hernias, the most common type in men. One group was treated by surgery, the other advised to postpone an operation unless the hernia caused symptoms.
The results show that not rushing to get a hernia repaired has not resulted in a host of problems. About one in five patients eventually required a hernia repair due to pain. And one patient needed surgery due to a bowel obstruction. But the overall results of expectant waiting were good.
Inguinal and other hernias are repaired for two main reasons, pain and the possibility of bowel obstruction. But bowel obstruction is a rare complication occurring in about two in a thousand cases, much better than the odds at Las Vegas. And most hernias do not cause significant pain.
This study is good news for those who wonder if they’re headed for trouble by avoiding a hernia operation. But this is not the first time that patients have been better treated by tincture of time, rather than the scalpel. In fact, this hernia study is long overdue.
For years parents were told as if it were God’s will that their children’s tonsils should be removed. I’m sure mine were removed at a young age for no good reason. Now we know that this was often needless surgery.
Gallbladder surgery is another prime example of surgeons too eager to operate. In the past the presence of gallstones was considered justification for removal of this organ. Today, abdominal ultrasounds are done for many reasons and it’s not unusual to discover gallstones which are not causing symptoms. Or they’re found unexpectedly during an autopsy.
Gallstones may remain silent for years. And unless they trigger abdominal pain or block the common bile duct causing jaundice, an imperfect gallbladder should be allowed to rest in peace.
The same can be said for many hernias. A wise sage once remarked that “if it ain’t broke don’t fix it”. We can now add “if it’s just partially broke don’t fix it when it’s not causing trouble”.
Never forget that there is no such thing as a free lunch with surgery. At the Shouldice Hospital 96 per cent of hernia operations are performed using local anesthesia which eliminates one risk. In most hospitals general anesthesia is used and although deaths are rare from this they do happen. There is always the risk of an incision becoming infected and at most hospitals a recurrence rate of at least 10 per cent. At Shouldice the success rate is virtually 100 per cent if there’s been no previous surgery.
Before any operation it’s prudent to ask yourself this question, “How much is this problem really causing me?” Today this question is even more important to consider as more and more procedures are available to ease annoying chronic problems.
I’m not against eradicating troublesome discomfort but I often see patients who have scheduled hip or knee replacements. But if I walked as well as they did and had only mild pain I’d run for the woods rather than have this surgery. People forget that these are major operations that require extensive post-operative physiotherapy, considerable self-motivation and do not always guarantee a good result.
My advice, whether it’s a hernia operation or some other surgical procedure, be as cautious as porcupines who make love, very, very carefully.