by Clive Couldwell
Many doctors used outmoded types of surgery for hernias, hand over this complicated operation to inexperienced juniors or experiment with new, untried techniques.
The statistics are worrying. It’s four times more dangerous to have a hernia operation than to go without one if you’re over 65, according to the Harvard School of Public Health (New Eng J of Med, 6 December 1973). Death rates vary 14 fold between health districts, and up to 20 per cent of operations have to be repeated within five years. To make matters worse, this recurrence rate rises to 30 per cent following a second operation and by as much as 50 per cent after the third.
In the UK, many patients are stuck on long NHS waiting lists. When it’s their turn for the knife, the quality of surgical skill required is described as, as best, “variable”, partly because the techniques used to perform the hernia repair vary.
“In the past there have been many types of hernia repair hundreds of different sorts,” says John Alexander Williams, a surgeon who has carried out a number himself. “The fact that there are so many is a clear indication that most of them aren’t good because a lot have been tried and superceded.”
Perhaps surprisingly for such a common operation, a good hernia repair is as difficult to perform as complex cancer surgery, so you might think it demands and receives the skills of an experienced surgeon. Not so.
Consultant surgeons are reluctant to specialize in such operations which they regard as mundane and routine. Often, trainee surgeons are left to cut their teeth on hernia repairs and a lack of general interest is partly to blame for their use of surgical techniques which are considered out of date.
“Surgeons are a very conservative bunch and they tend to continue doing the same things if, as the old phrase goes, it works in their hands,” says Andrew Kingsnorth, a consultant surgeon at the Royal Liverpool University Hospital and hernia expert. “But we know that experience can consist of doing the wrong things over and over again. This is what’s happened in hernia surgery.”
A hernia is a bulge, usually in the groin, caused by a weakness in the muscles which form the front wall, or lining, of the abdomen. Surgery pushes back the contents of this bulge and supposedly strengthens the ruptured muscles and ligaments.
Around 80,000 of the estimated 150,000 or so patients who develop hernias each year are admitted for surgery. The abdominal wall may weaken with the passing of time. Sometimes the muscles may be put under a sudden increase in pressure through heavy lifting, sport or coughing. Hernias may occur if you’re overweight, or due to the stretching of scars from previous surgery.
There are many different types of hernia, such as the umbilical (near the belly button), inguinal ( the groin), scrotal and femoral (thigh). If left untreated, hernias can get bigger and may cause pain. Sometimes a part of the intestines can slip in and out of the hernia, an entrapment which can lead to permanent strangulation, producing severe pain and sometimes vomiting.
Unfortunately, three out of four surgeons repair the rupture by “darning” it with a criss-cross of stitches that can give way under too much tension. The modern era of hernia surgery began in 1887 with the so-called Bassini operation, named after an Italian who published his techniques in the German medical literature of the day. Although he devised a very effective operation, it was corrupted over the years in the hands of very average surgeons and was successful in only 10 per cent of cases.
Unfortunately, the “darn” is entrenched in surgical practice because it is simple. Junior surgeons, who currently tend to do the bulk of hernia surgery, can pick it up very quickly.
In the 1950s and 1960s, the Bassini technique was resurrected by the Shouldice Clinic in Toronto, which began to produce excellent results.
The Canadian Shouldice technique reinforces the ruptured abdominal wall by stitching through three layers, compared with the one layer of the older method. The tissue overlaps, like a pleat, to create a stronger bond. The Shouldice operation is more difficult. It also takes longer because it incorporates four layers of sutures. “It has to be done meticulously, and if you get one or two of the stitches wrong it falls apart,” says Andrew Kingsnorth.
Patients given Shouldice hernia surgery spend less time in hospital, experience less pain after the operation, and fewer than 1 per cent have to return for another operation.
Or so the story goes. But, there’s a snag. “You can’t just read it in a
book and pick it up,” says Andrew Kingsnorth.”You have to be taught it, and only 20 per cent of surgeons in the UK currently practise this technique.”
Junior surgeons at the Shouldice Clinic in Toronto are closely supervised for the first 50 hernia operations and don’t operate on their own until they’ve notched up 50 more. They’re then assessed for a second time after the thousandth hernia repair.
“Only after this assessment is the surgeon considered a fully-fledged, independent operator,” says Andrew Kingsnorth. “Our present supervision in Britain of only six herniorrhaphies is therefore clearly inadequate” (see also Br J Surg, October 1992).
Concerned by the figures and quality of hernia repair surgery revealed by charting the trend through its Hospital Activity Analysis Statistics, the UK Department of Health recently invited the Royal College of Surgeons (RCS) to find out whether surgical techniques could be improved.
Their conclusion: there was no clear cut, best practice hernia surgery being taught or available within the standard textbooks for surgery.
One fundamental issue on which there is general agreement is the importance of constructing a solid repair without tension. This can be done by using either the patient’s own tissue or a piece of prosthetic material, such as the mesh. The Lichenstein mesh (named after a shrewd businessman who made a small fortune commercializing a technique which surgeons had quietly been using for 20 years), uses a polypropylene patch, or mesh, which is stitched over the rupture, making the repair much stronger and less likely to break down. Andrew Kingsnorth has pioneered this method on the NHS after visiting the Lichenstein Hernia Institute in Los Angeles, California, whose head, Alexander Shulman, claims the failure rate is substantially lower than 1 per cent.
Private clinics, such as the British Hernia Centre and the London Hernia Centre, perform mesh surgery under a local anesthetic. The operation is usually completed in a day, and they recommend that deskbound patients return to work after a few days.
Proponents of its liberal use (ie, those with a commercial interest) claim that reinforcing mesh offers significant advantages over traditional methods of repair (Am J Surg, 157;188: 1989).
However, at some institutions, mesh is recommended in less than 1 per cent of patients with groin hernia (Surg Cl of N Amer, 1993; 73(3): 513).
In a review article about current practices in hernia surgery, Volker Schumpelick of The Department of Surgery at the Rhenish-Westphalian Technical University in Germany, the author of a book on hernia operations, and his colleagues point out that the person who developed mesh repair in Europe limits his technique to patients above 50, because of the “unknown long-term fate and side effects of the implanted mesh material (The Lancet, 6 August 1994).
“Indeed, almost nothing is known about the biological compatibility of these materials in the very long term. . . . Since the average life expectancy of patients with hernia repair is more than 20 years, this potential hazard must be considered,” they wrote. Schumpelick only recommends mesh when groin ligaments are unusually weak.
The general consensus among doctors is that hernias in all cases requires surgical repair (other than those patients who are terminally ill or very old and frail).
Most people aren’t given the truth about leaving well alone, the dangers of which, in some instances, are vastly overplayed with little scientific evidence. To attempt to quantify this risk, a group of surgeons at the University College and Middlesex School of Medicine in London calculated the cumulative probability of strangulation for all hernia cases at their hospital between 1987-89.
The risk of strangulation for groin hernia was 2.8 per cent after three months, rising to 4.5 per cent after two years. However, for femoral hernias, the likelihood of strangulation was 22 per cent at three months, rising to 45 per cent after 21 months.
The probability rate increased fastest during the first three months, suggesting that if you have a new hernia you are at higher risk than someone who has been carrying one around for years (Br J Surg, 78; (10): 1171-3). Schumpelick and his group say that direct hernias particularly broad direct bulges are 10 times less likely to strangulate than indirect hernias.
Doctors also underplay the risks of hernia surgery particularly of repeat operations. Usually the risk of dying from the operation is under 0.01 per cent in elective surgery. This risk rises to 5 per cent in emergency cases and among elderly patients. Other complications include injuries to the nerves and vessels of the spermatic cord, leading to the trapping of a nerve and long-term pain on the upper side and groin and even the back. Another worry is orchitis painful swelling of the testis which in 40 per cent of cases can lead to testicular atrophy.
This complication is rare in first time cases (0.03-0.5 per cent), but
increases by 10 times in recurrent hernia operations (The Lancet, 6 August 1994).
One study showed this complication could be minimized by leaving all
hernia sacs intact, not cutting beyond the tubercle (bulge) of the pelvic bone and using the intra-abdominal wall approach for recurring hernias (Surg Gyn Obstet 1992; 174: 399-402).
Clive Couldwell frequently writes for the London Times and the Telegraph.