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CASE NOTES
Tuesday 21 March 2006, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION

RADIO SCIENCE UNIT

CASE NOTES

Programme 11 - Hernias

RADIO 4

TUESDAY 21/03/06 2100-2130

PRESENTER: MARK PORTER

REPORTER: BARBARA MYERS

CONTRIBUTORS:
ANDREW KINGSNORTH
MARK WOODWARD
TONY MILES

PRODUCER: ERIKA WRIGHT

NOT CHECKED AS BROADCAST

PORTER
Hello. One in four men, and one in thirty women, will develop a hernia in the groin or abdomen at some stage during their life - and having been one of them, I must declare a vested interest in today's programme.

So why do so many of us develop hernias? Does having a hernia always mean an operation? And if yours does require surgery which procedure should you go for - the conventional open repair, or the newer keyhole laparoscopic approach?

And who should you get to do it?

All questions I hope to answer over the next half hour with the help of one of the UK's foremost experts in the field, the President of the British Hernia Society, Professor Andrew Kingsnorth.

KINGSNORTH
A hernia is a defect in the abdominal wall and the defect occurs where there is a gap between the muscles and through that gap the hernia itself protrudes. Now these gaps occur in various sites, the main site they occur in is in the region of the groin where the leg/thigh joins the abdomen, that's called an inguinal hernia. But also you can get hernias around the naval, we term that area the umbilicus, so that's called an umbilical hernia. And also lots of patients have surgery performed on their abdomen and they have an incision, a cut in it, so that the surgery can be performed and often that scar weakens, a gap appears and that's called an incisional hernia.

PORTER
Most abdominal hernias develop in people over the age of 50 - either as a result of general weakening of the tissues due to wear and tear, or following injury after strenuous activity such as lifting something heavy. They can even be one of the many side effects of smoking - and not just as a result of prolonged coughing.

KINGSNORTH
It's an effect that tobacco has on the tissues. If you look at a patient who's a lifelong smoker they look at least 10 years older than their age and that's because the connective tissues, the tissues of the body, degenerate and the tissues of the groin degenerate and causes hernias. But most patients it's just a process that occurs without a sudden traumatic event.

PORTER
Groin hernias can vary tremendously in size, what's the biggest one you've seen?

KINGSNORTH
The biggest hernia I've seen was a hernia that was actually brushing the floor. I've seen quite a number which go down to the patients' knees and these are what are colloquially known as wheelbarrow hernias. They're common unfortunately in the developing world and I've operated in Africa and other places where unfortunately it's not uncommon to meet patients with wheelbarrow hernias.

PORTER
Do we need to operate on all hernias?

KINGSNORTH
No. In say an elderly man who just has a small bulge and a doctor has seen and assessed the patient and judged that there's no risk of complications, such as strangulation, then it doesn't require surgery. There has been a recent study done in America called the Watchful Waiting Trial where about a thousand patients were watched who had asymptomatic hernias. And the complication rate was extremely low, only one or two patients required emergency surgery and the other patients didn't have any ill effects from just having their hernia watched.

PORTER
And a danger with not operating would be?

KINGSNORTH
The danger would be that the complications occur such as the hernia enlarges, that the bowel gets trapped in it and twisted and that's called strangulation which actually has a mortality risk, a death rate, if you do get twisting of the bowel in a hernia and strangulation then you may stand 10-20% instance of mortality.

PORTER
And if you were to see someone with a groin hernia that you weren't keen to operate on, maybe they weren't particularly fit themselves, what about the hernia would reassure you that it was a safe one to leave?

KINGSNORTH
One that was painless, that when the patient lay down it reduced itself without any pressure, and probably would have to be a middle aged or elderly man, I think in younger males where there's the life expectancy of 50 or 60 years one would almost certainly advise that the hernia was repaired.

PORTER
Well to find out what repairing a hernia actually involves, I joined Professor Kingsnorth on one of his busy all day operating lists at Derriford Hospital in Plymouth. By the time I got there he was just about to start on his third case of the day - a 57 year old gentleman with bilateral groin or inguinal hernias.

ACTUALITY
PORTER
When did you first notice that you had a problem?

PATIENT
About 12 months ago. Slight discomfort, I wouldn't say it was pain, but the swelling was there and it was on both sides.

PORTER
Had you been doing anything that you thought might have brought it on?

PATIENT
No just wear and tear I think.

KINGSNORTH
This is an open hernia repair. So we're making an incision in the patient's groin, it's about three inches long. This is the way in which about 90-95% of hernias will be repaired at this point of time in the United Kingdom.

PORTER
The classical story was that the general public think that you have to be doing something and something rips and tears and lo and behold you get a hernia. But it doesn't often happen that way does it?

KINGSNORTH
About one in six occur that way, about one in six patients can relate a strenuous event to development of a hernia. But with most patients there's - as this patient mentioned actually - a bit of wear and tear, the ligaments of the groin stretch and weaken and gradually a bulge appears.

PORTER
What is it about the groin though that makes it such a common site for hernias?

KINGSNORTH
It's where there's an anatomical junction between the thigh and the abdomen and having adopted the upright posture, humans adopt the upright posture, it's a natural area of weakness, so it's a penalty really of human development. The hernias don't occur often in other types of animal.

PORTER
While hernias can occur at any age, there are two periods in your life when you are most likely to develop one - in middle age and beyond, or before your first birthday.

Inguinal hernias in young boys normally result from a congenital weakness in the groin caused by the descent of the testicles through the abdominal wall and into the scrotum. The testicles start life off inside the abdomen - like the ovaries - but then migrate into the scrotum just before birth. Unfortunately the trail they leave doesn't always heal up properly, allowing other abdominal contents to follow them and cause the characteristic hernial bulge. Mark Woodward is a surgeon at the Bristol Children's Hospital.

WOODWARD
Overall about three or four per cent of new-borns will have a hernia but that congenital defect that can manifest at any time in childhood.

PORTER
Routinely a child's examined when they're born, they're examined again often by their GPs at around six weeks, when are most hernias picked up?

WOODWARD
Any time really throughout childhood. I mean the typical story would be that the child's parents would notice a lump in the groin when they're crying and the majority would be in infancy, in the first year of life, but it could happen at any time in those first few years.

PORTER
And will these congenital defects close up on their own or do they always need some form of surgical intervention?

WOODWARD
They will never close on their own, they're always going to need surgery and in infancy, in the first six months of life, we try and operate fairly promptly as there is quite a high instance of a bit of bowel getting stuck and causing the child a lot of pain. In the next few years of life there's not quite so much of a rush and we tend to just wait for the next elective slot in a few months.

PORTER
And what other sort of hernias do children get?

WOODWARD
The common ones that you see are umbilical hernias associated with separation of the cord, they can get some rarer hernias around the diaphragm, separating the abdomen from the chest.

PORTER
The umbilical hernias - the tummy button hernia - is something that I see in practice quite often, generally we leave those alone, those do tend to heal on their own don't they?

WOODWARD
Yeah that's right, they're very common - about 1 in 25 new-borns will have an umbilical hernia. There's a defect in the muscle there at the point at which the cord is attached and when it separates and the skin then covers then it over you're left with this defect and it's often the cause of concern for parents, if they have their infant crying the hernia will be obvious and they think that maybe the hernia's a cause of discomfort. And we spend a lot of time reassuring parents that in fact it's not at all, it's just there because they're crying. But the natural history of these is for them to usually close spontaneously and we never intervene below the age of three usually. We often follow children up until that point and if it's not gone have a discussion about whether we should or shouldn't close it. It's extremely unusual for a hernia at the belly button to get stuck.

PORTER
And why is that - is it because they're quite base are they?

WOODWARD
Yeah, yeah that's right, I've maybe seen it once in the last six years, it's really uncommon, so we tend to just sit tight.

PORTER
Back at Derriford Hospital, Professor Kingsnorth has started repairing the second of his patient's bilateral groin hernias.

ACTUALITY
KINGSNORTH
So I've just made the incision through the skin here and we can now see the first anatomical layer of the groin. There are several layers here but we haven't yet seen the hernia, so we've got another layer to go through and we're just opening the leaves of a book here, in effect. So once I've opened this layer we'll very clearly be able to see the hernia underneath. Now - I've now opened the book, as it were, I've got in my forceps here the hernia sac. So I'm going to just set the hernia away from the spermatic cord, which is the next step in this operation. Then we'll be able to see exactly where the hernia is protruding from and through. And then I'll show you what we do to repair it.

PORTER
Now that hernial sac that you're looking at there is - is there anything in it, is that empty?

KINGSNORTH
I don't know yet, we'll have a look, it seems to me that it looks as if it is mainly fat, which is not uncommon. So it's like having an empty balloon, as it were. When the patient stands up the balloon fills with contents, as it were, and they maybe intestines, they may just be fat and when they lie down that balloon, that sac, is collapsed. So in fact this patient has two problems here, he has this fat coming out of what we call the internal ring and it's a lipoma of the cord so called, very often seen with hernias, but also this is his hernia here, it's a direct hernia. So this is a definite wear and tear hernia. You can see a very saggy posterior wall with the protrusion about - I guess about the size of a golf ball when it would be full is coming out of the back wall - the posterior wall of this inguinal canal. So to treat this hernia effectively we have to remove the lipoma and then we will just flatten the posterior wall with a suture and then we will place the prosthetic mesh on the posterior wall of the inguinal canal. And it's made of an inert material - it's polypropylene - it's a bit like mosquito netting really. And we use a patch that's about twice the size of a cigarette packet if you like. Now the mesh itself is stronger than the patient's own body, so once it's been incorporated into the tissues it can't be damaged by the patient, they can go and pump weights, run a marathon once the wound is healed.

PORTER
When you say once the wound is healed that's how long after the operation?

KINGSNORTH
Our patients we advise them to be - to not take part in anything very strenuous for about two weeks. If they feel comfortable and they're not getting pain with certain activities then we would tell them well you just carry on as you wish with no restrictions, other than those limitation by pain. So I'm just going to trim a small area off this mesh, so that it will fit into the groin. Now I've got a nice long strong continuous suture here, which is suturing it to one of the ligaments around the groin.

PORTER
And it's fixing the edge of the patch down.

KINGSNORTH
Yes that's right, I've sewn the edge of the patch down and I'll now just slit the mesh to accommodate the spermatic cord, so they'll just be a keyhole slit in that mesh allowing exit of the spermatic cord.

PORTER
What's the difference between this type of modern mesh repair and repairs that we were using 20 years ago?

KINGSNORTH
When we just used suture material the recurrence rate was probably 10% even 15% but with this mesh if you look at results of people who do a lot of hernia surgery their results - they should produce about a 1-2% recurrence rate. But if you look at surgeons in general, such as have been looked at in Sweden and Denmark, you find the recurrence rate is probably about 5% in the hands of general surgeons, all comers. Now you can see this is - actually the hernia repair is not a difficult procedure. It's estimated that you can become competent in this operation by probably performing about 20 or 30. With the laparoscopic operation recent studies show that you actually have to probably do about 200 before you're good at the procedure because it's much more difficult. Once you're off that learning curve you'll be doing a very good operation, that will produce excellent results but there is a long learning curve and of course you have to ask the question what happens to the 200 patients on somebody's learning curve.

PORTER
While I was in Plymouth, Barbara Myers was in Worthing Hospital watching one of those laparoscopic hernia repairs - where the mesh is placed on the inside of the abdominal wall using keyhole techniques. Imagine repairing a puncture in a tyre by putting a patch inside the tyre, rather than the conventional method of placing it over the hole on the outside.

ACTUALITY
DOCTOR
Right Mr Smith so you're going for your operation this afternoon and you know what we're going to do don't you - keyhole hernia repair, so laparoscopic hernia repair. And it's on the left side isn't it that's bothered you and you've had that done previously haven't you? Okay. So what we're going to do today...

MYERS
Surgical registrar Angela Scowl [phon.] getting Mr Smith to give consent for the laparoscopic surgery he's about to undergo for his bilateral hernia. About 10% of the hernia operations at Worthing Hospital are done laparoscopically, most of them by consultant surgeon Mr Tony Miles.

ACTUALITY
MILES
The whole operation is going to be done with micro-instruments, so these are the hands, if you like, that are going to go inside the patient. Can I have the [indistinct words]? So we've got the hernia here is just protruding through a small hole and very gently using the little metal grasp I can get hold of that and pull it back inside the abdominal cavity. Sean, could you just turn that TV screen towards me slightly? Yes that's great. And now you can see the hole that the hernia's going out through.

MYERS
So you're kind of reeling it back in.

MILES
Yeah.

MYERS
And what is the size of the - I can't get the real true size of it - that hernia.

MILES
Well the defect this has gone out through is less than a centimetre in diameter.

MYERS
And why have you chosen to do this - the laparoscopic procedure - instead of the open procedure on this particular patient today?

MILES
This operation is suitable for some people for special reasons - a particular need to get back to work very quickly, now this gentleman, I would expect, would be able to get out of the hospital tomorrow morning, pretty well pain free and he'll be back to normal activity probably within a week. He plays tennis I think, so he's keen to get back to his tennis.

So there's a chronic defect now. And I think there you can see the blue suture.

MYERS
Oh yes that's quite clear isn't it. The old stitch from the old operation.

MILES
So that'll be a nylon stitch and you can see it's just gone in the gap between the two stitches which is a common finding for this type of thing. Very near to here there's some very big blood vessels, now that is the main vein which runs down through his leg and if you were to damage that, that would be quite difficult to fix. So - and it's within a millimetre of where you have to operate. So the potential for problems with laparoscopic repair is there, there's no doubt about that.

MYERS
You're making me nervous now.

MILES
Well I think the government has been given us very good advice about how we should treat the repair of hernia, in that people should have specific training to do laparoscopic surgery because if it's done properly it has advantages but there are risks involved with laparoscopic surgery which are just not present in open surgery and that has to be recognised. So there we go, that's looking very good now. I now have a space which is probably big enough, so nice big cavity for the mesh to go into.

MYERS
The operation has taken about an hour, it ends up with just one or two stitches in each of the three tiny incisions. While the surgical team tidies up I asked Mr Miles to sum up the pros and cons of this type of surgery.

MILES
The advantage of the laparoscopic approach are less pain and earlier return to normal activity. The disadvantages are it's technically more complicated and there are very slightly higher risks.

MYERS
Of what - the risks of what?

MILES
Well the problem with laparoscopic surgery is you're inside the abdominal cavity and there have been reports of damage to the bowel or damage to the blood vessels inside the abdominal cavity which just don't happen with the open technique. The advice with the open technique is it's technically simple, straightforward, very, very low risk profile, very low recurrence rate but the disadvantage is it's painful and so you have more discomfort in the first few days after your operation. And that really sums it up.
MYERS
And so if someone says doctor which operation am I going to have, why would it be laparoscopic in this case if they come to you, because that's your approach, how might you persuade them that that would be actually the best all round for them?

MILES
Yes, we've had very good advice from the government, from the National Institute of Clinical Excellence, and what they've recommended is that for bilateral hernias and for recurrent hernias is a definite advantage in laparoscopic technique and for a single site of first time hernias then that should be discussed with the patient - the pros and cons of each technique - and then the operation fitted to the patient's circumstances.

KINGSNORTH
I think any patient who's going to a surgeon and is offered a laparoscopic operation they should quiz the surgeon on his experience, how many he's done, it requires at least 200-250 to become expert in it and what their results are. And if that surgeon has a good experience and good results then he will give them an operation that is as good as the open technique.

PORTER
But can you give me an advantage of having it done laparoscopically?

KINGSNORTH
The early data suggested that patients recovered more quickly from the laparoscopic operation because it was done through keyholes. But in fact you've watched me do an operation today and you can see that the trauma even caused by the open operation is very minimal and the recovery time from the open operation is probably no more than one day, on average, more than the recovery from a laparoscopic operation which in terms of practical economics is insignificant.

PORTER
Now I've got a confession, I had a patch - mesh repair - done myself on a hernia two years ago and it all went quite smoothly but I did get a little bit of pain afterwards and I still get pain every so often. Is that a common complication?

KINGSNORTH
Yes. I think that anybody who studies any surgical incision will find that there is post-surgical pain, whether you've had your incision in the abdomen, on your shoulder, your knee, your chest, it's no higher in the groin than any other site in the body. However, about 3% of patients suffer what we call chronic groin pain in that rather than just getting the occasional twinge or if they lift something heavy they get an ache in the groin, they have the type of pain that impairs their normal quality of life and these are patients that at the moment we're not quite sure what the cause of this chronic groin pain is. It may be related to surgical technique, being a bit clumsy with the small nerves around the groin and damaging them. There is some suggestions it might be due to the mesh but at the moment there is no evidence at all to suggest that these meshes that have been around for about 30 years are responsible for chronic groin pain.

PORTER
What about the chances of getting a hernia on the other side, in fact I had mine on my left two years, what are the chances I'm going to get another one on my right?

KINGSNORTH
You stand about a four times increased risk of getting a hernia on the other side than a member of the general population.

PORTER
Which means?

KINGSNORTH
The lifetime risk for men is 27%, the lifetime risk for women is 3%.

PORTER
So 27% times four is a hundred per cent or more than a hundred per cent.

KINGSNORTH
Probably manipulating the statistics there.

PORTER
Talk to them enough and they'll tell you anything but it's quite a high chance basically.

KINGSNORTH
There is yes.

PORTER
Andrew Kingsnorth also deals with a lot of incisional hernias - hernias caused by a weakness in a previous surgical scar - and he's about to start repairing his second of the day.

ACTUALITY
PATIENT
I had an appendix out when I was on holiday in Lanzarote and I've always have been in a bit of pain after really but really it didn't start to showing until about four or five years ago.

PORTER
So you noticed the swelling there did you?

PATIENT
Yeah, yeah yeah.

PORTER
So then what did you do?

PATIENT
I went to the doctor and he said he couldn't feel anything so he said it was probably just muscle. And so I didn't do anything until Easter when I had a really bad cough and I felt the pain.

PORTER
Now this lady had her appendix out, that was the initial operation, and normally you'd have a little tiny scar in the groin but this is an unusual incision isn't it.

KINGSNORTH
It's what we call an incision created at St Else Where's. In other words by another unnamed surgeon. And it is an unusual incision, it's a vertical incision and it's also not in the middle of the abdomen, it's about three inches from - to one side of the naval. And unfortunately this type of incision is quite prone to formation of incisional hernia.

PORTER
What actually happens in an incisional hernia?

KINGSNORTH
You can get early failure of the suture closure, which is definitely a technical failure, it's a failure by the surgeon really - either the knot has come undone, the stitch itself has torn out or the suture material is broken. And the second type of failure is where the tissues around the scar gradually degenerate and it begins to bulge, until finally the patient develops a hernia. And actually when we talked to this patient here it was obvious that her - she was aware of some discomfort fairly soon after the operation, almost certainly that was when the hernia began and a few years later she became aware of this large bulge when there'd been significant degeneration of the scar. There are several tens of thousands of incisions made in the abdomen each year and we know that 10-15% of those will fail and produce incisional hernias.

PORTER
And are incisional hernias dangerous if they're not treated or is it just a matter of inconvenience?

KINGSNORTH
It has been thought for a long time they're not dangerous which is why a lot of patients are told that they just need to wear some sort of support and no active treatment or surgery is required. But there is a significant risk in some of these bigger hernias that the bowel will get trapped and twisted and strangulation occur. But there are other reasons as well - they cause significant cosmetic problems for the patient, and you can see this patient will obviously have difficulty wearing normal clothing because she's carrying a melon sized lump on her abdominal wall.

PORTER
We talked about a failure in the way that the wound is closed can lead to an incisional hernia but what about factors in the patient - are some types of patient more prone to suffer from incisional hernias?

KINGSNORTH
Yes. The chief risk factor is obesity. And I would say in the majority of patients we repair are significantly overweight.

PORTER
Does it bother you that these patients who have been operated on once, the scar's broken down, possibly because of a surgical failure, you're under quite a bit of pressure to get it right this time, does it make you extra careful?

KINGSNORTH
It does. The recurrence rate for repairing an incisional hernia is in the hands of experts still a figure of about 5% and that's because many of the patients, as I mentioned before, have poor tissues and are obese. In the hands of people who don't have a special interest in the repair of incisional hernias the recurrence rate may be as high as 50%, as recently shown in published clinical trials.

PORTER
Fifty per cent - that's very high.

KINGSNORTH
I get a lot of hernias that have been repaired sometimes four, five and six times and they come to me from other centres where they've really decided that they can't fix the patient's hernia and they want someone who has a special interest and a few additional tricks up their sleeve to see if they can have some success.

PORTER
Perhaps we should finish with some specific advice for people with hernias. What criteria might suggest to you, as a doctor, that someone who's got a hernia needs to have it repaired, what would worry you about a hernia?

KINGSNORTH
The main factors would be the size of the hernia and whether the hernia was causing pain. If a hernia is small and an insignificant bulge and it's painless then it may be an option for the patient not to have surgery. But if a hernia is a significant size, let's say it's getting to the size of a cricket ball and it's painful, then almost certainly surgery is required.

PORTER
I'll put you on the spot. If you had a hernia and you were given the choice to have an open mesh Lichenstein repair or a laparoscopic repair, done by expert surgeons in both, which would you go for?

KINGSNORTH
I would choose an open Lichenstein operation under local anaesthetic for myself because it's simple, it has a better recurrence rate than the laparoscopic operation, the recovery is fast and it can be performed without general anaesthesia.


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