DEAR READER: An inguinal hernia occurs when a portion of the small intestine or internal fat protrudes through a weakened area in the lower abdominal muscles. This occurs on either side of the groin area between the abdomen and thigh, resulting in a bulge. Inguinal hernias are five times more common in males than in females and account for 75 percent of all hernias, of which there are several kinds. An inguinal hernia can occur at any time from infancy to adulthood.

There are two types of inguinal hernia — direct and indirect. A direct hernia is caused by degeneration of connective tissue of the abdominal muscles, common in older people. This type develops gradually because of continuous stress on the muscles involved. Factors include weight gain, lifting heavy objects, muscle strain, chronic cough and straining from constipation. Indirect hernias are congenital and much more common in males because of the way a male develops in the womb. Indirect inguinal hernias can occur in females as well; however, the condition is the result of a weakened area in the abdominal wall, not because of a weakened area of the inguinal canal.

Symptoms of either type include a bulge, pain, burning or discomfort — especially when lifting or otherwise straining — and weakness or pressure in the groin. Incarcerated hernias are so named because the bulge that protrudes is swollen and cannot be massaged back into the abdomen. When this occurs, the blood supply to that area may become compromised. Symptoms can include fever, increasing pain, tenderness, redness and an elevation in the patient’s heart rate. This situation requires immediate attention.

Diagnosis of an inguinal hernia is made through examination by a physician and the medical history provided by a patient.

Treatment for adults is surgery accomplished either through laparoscopy or open repair. The laparoscopic approach uses general anesthesia. Incisions are made in the lower abdomen. A thin tube with a video camera is then attached. The camera allows the area to be viewed on a monitor, and repairs are made using synthetic mesh. This procedure affords shorter recovery time but cannot be used on large hernias or on patients who may have had prior pelvic surgery. Open repair requires anesthesia into the abdomen or spine to numb the area. An incision is made in the groin, the hernia is repositioned into the abdomen, and the abdominal wall is reinforced with sutures. The area is then strengthened with synthetic mesh or screen in a procedure known as herniorrhaphy.

Post-surgical conditions can include wound infection, bleeding, pain at the site of the scar and injury to internal organs. Recurrence can occur. Generally speaking, however, hernia repair using either method is safe and most often uncomplicated.

To provide related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery.” Other readers who would like a copy should send a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092-0167. Be sure to mention the title or print an order form off my website at www.AskDrGottMD.com.

In October 2008, a blood clot was found between his knee and ankle on the back of one of his legs. He is currently taking Coumadin to keep the blood flowing and reduce the possibility of further clotting.

In November 2008, he was found to have an incisional hernia in his abdominal area, which was the result of the August surgery. No one would operate on it until six months had passed from the discovery of the blood clot because of the risk. Every physician we spoke to said something about this being “generally accepted medical theory” regarding blood clots and surgery, etc.

In April 2009, the surgery for the hernia occurred. During the time that elapsed, it had become huge. It made his abdomen look as if he were nine-months pregnant, and he had significant discomfort.

As part of the hernia surgery, they made a big incision to try to reposition everything as it should be and added the mesh. After the surgery, the hernia was contained and everything looked terrific, but within a day or two, it was obvious that it had failed. The surgeon finally admitted this in June 2009.

At that point, the surgeon told my husband that he needed to lose weight before surgical repair could be considered again. We were told that this is necessary because his first hernia repair had failed because his stomach muscles were too weak to hold due to the fat in his abdominal area. I told the doctor that the reason my husband’s stomach muscles had become weakened was caused by the six-month delay in doing the surgery in the first place. If it had been done sooner, the muscles would not have become weakened to this degree. The surgeon then told me that he had no input into that decision or in advising us in that regard.

My husband is now trying to lose weight, but he can only walk because other exercises put too much strain on the hernia. He currently weighs 300 pounds. If he is to lose a significant amount of weight, it will take a huge amount of time, and the hernia will continue to go unresolved.

Is there anything that can be done in the interim to try to contain the hernia?

DEAR READER: Blood clots can develop for a number of reasons, including clotting disorders, being over 60 years of age, obesity, pregnancy, prior surgery, cancer and more. Because your husband had major surgery to remove a cancerous tumor, he was at an even greater risk of developing a blood clot.

Incisional hernias are also a possibility following surgery. They are typically associated with traditional surgeries that involve larger incisions.

Because I am not a surgeon, I do not know what standard guidelines are followed in treating a patient with a blood clot for an unrelated condition. Those with blood clots or other clotting disorders that require the use of anticoagulant therapy, such as the Coumadin your husband is taking, who require any type of surgery, are usually told to discontinue the medication a week or two prior to prevent hemorrhage or excessive blood loss. However, this recommendation is likely for those who are well established on the anticoagulant and have been stable for an extended period.

As to your husband’s worsening hernia and why his surgeon waited for the six-month mark, I am not only surprised but disappointed. He should have been informed of other options in the interim. Even though it’s not a cure, your husband probably would have benefited from the use of a girdle or elastic support garment that would have put pressure on the area of the hernia, helping it to stay in place. It is also important to avoid activities such as bending or heavy lifting that place excessive strain on the abdomen. Obesity can worsen hernias.

I am shocked that your husband’s current surgeon blamed his hernia on abdominal fat and weakened muscles. Clearly, he had just undergone major surgery to remove a diseased organ and was probably still recovering from that when the blood clot and hernia developed. After such an ordeal, one can hardly be blamed for not being as active and fit as before, especially immediately following the situation.

While I believe your husband would be better off losing some of his excess weight, I do not think that postponing the hernia repair is in his best interests. I suggest he begin his weight loss by following a simple diet plan, such as my no-flour, no-sugar diet, exercising as much as possible without overdoing it, and seeking a second opinion.

In April 2005 I had an abdominal aortic aneurysm which burst while I was on the operating table. Against the odds I lived.

In July 2005 I developed two hernias which were treated non-invasively. In April 2006, I developed three hernias which were again treated non-invasively.

In May of 2006 I had surgery on my left carotid artery because it was 95% blocked. I was fine until March 2008 when I had to have surgery for another hernia. I have enclosed the hospital papers with this letter for your review.

Aug 2008 I returned to the same hospital because of more hernias. The doctor said they could not operate and that I would have to be seen by a specialist at a nearby medical university hospital or the Mayo Clinic. He said they couldn’t do the repair because any further operation might cause me to lose part of my stomach and/or large intestine. I have been wearing an abdominal binder but the bulges are very prominent and painful, especially when I cough which was often since I have COPD.

DEAR READER:
Thank you for sending some back up material as it was helpful in coming up with my answer.

Based on the report, all of your hernia problems have come from your abdominal aneurysm repair. The surgical incision has weakened in several areas allowing the hernias to form. During the first surgical repair, mesh was put in place to prevent further weakening of the area. During the second surgical repair, a new hernia occurred just on the edge of the old mesh and that the old mesh has grown into the flesh. You also had several severe adhesions (areas where two organs fuse together inappropriately). The adhesions where removed, as was the old mesh. A new, larger piece of mesh was put in place and the hernia repaired. At the same time, your umbilicus (belly button) was removed because it had adhered to the mesh.

All of this means that your while your first surgery successfully fixed the hernia, it eventually led to several potentially serious conditions caused by the healing process. Adhesions are essentially a buildup of scar tissue and in your case, this occurred between your stomach, small and large intestine and the surgical mesh. Your body healed too well which led to the problem.

Based on the findings of the second surgery and your current situation, it seems to me that you will continue to have issues with hernias. I am unsure of the cause of this, however, can understand the physician’s stance. Based on your last surgery, the hospital and surgeons are expecting more of the same. Even if your adhesions and hernias are less severe than the previous ones, damage has been done.

Removal of part of the stomach and intestine is major and can lead to complications. I agree with his recommendation to see super specialists at a teaching hospital or the Mayo Clinic. The physicians and surgeons here have access to the newest procedures and protocols. Perhaps they will be able to fix your hernias and prevent them from returning.

I urge you to make an appointment at one of the facilities for a consultation. Be sure to bring your medical records for review as they may play a crucial role in determining your next course of action.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped envelope number 10 and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

I’m 60 years old and carried mail for 34 years. I retired at the age of 55. I don’t know if my occupation has anything to do with my weak stomach lining or not.

My questions are, should I change doctors? Is there any other new procedure besides mesh? Does wearing a truss help any, and how many surgeries can be done on a stomach without causing further damage?

DEAR READER:
Hernias occur when soft tissue protrudes through a tear or weakened area of the lower abdominal wall. This can occur because of strenuous activity, coughing that accompanies smoking, or when muscles weaken later in life.

While some hernias go unnoticed, don’t cause any problems and aren’t discovered until physical examination, others cause great discomfort and are quite painful.

While anyone of any age — including infants and pregnant women — can develop hernias, they are more common in men. One reason might be that with the male fetus, the testicles form within the abdomen and proceed down the inguinal canal into the scrotum. After birth, the canal tightens, leaving adequate room for the spermatic cord to pass through, but inadequate room for the testicles to move back into the abdomen. A weakened area develops when the canal fails to close properly.

There are numerous reasons for a hernia to develop including obesity, chronic coughing or sneezing, straining during defecation or urination, and lifting heavy objects.

The most common, successful hernia repair performed today is hernioplasty, where a physician inserts synthetic mesh into the abdomen to cover the weakened spot. The mesh patch is secured with staples, clips or sutures. It is often done using a laparoscope so the surgeon can make several small incisions rather than one large one. This allows the patient to heal faster with less discomfort and to return to normal daily living sooner.

I cannot say if your 34 years as a mail carrier is the cause for your multiple hernia sites. Perhaps you returned to normal function too quickly, strain too often, or have other reasons for your many hernias. I must admit I have never heard of anyone who has had eight hernias and six surgical repair procedures.

In terms of wearing a truss, this is probably not in your best interests. Some surgeons recommend wearing them once a hernia is discovered until a surgical procedure can be coordinated, but they aren’t recommended for daily use.

I suggest you return to your surgeon and present your list of questions to him or her. If you don’t receive the appropriate answers, go back to your primary care physician and ask for referral to another surgeon. A second opinion is often the appropriate way to go.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped, number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

In February 2007, my husband was found to have high blood pressure and was started on lisinopril, hydrochlorothiazide and metoprolol which he took until October 2007 when he developed an unproductive cough, extreme fatigue and lightheadedness. He could sleep 24/7. He saw his doctor who ordered testing but nothing was found.

He then developed dizziness when turning his head or bending over and saw the doctor again after developing a slight fever. He was given amoxicillin. At that time we asked about the possible side effects of the lisinopril and were told he could stop it.

Now fearing medication my husband stopped them all. He then returned back to the physician because his symptoms persisted and was found to have very high blood pressure and a heart rate of 120. His cough had disappeared shortly after stopping the medications but he continued to be dizzy, lightheaded and tired. He was admitted to hospital that day where he had a chest X-ray and was seen by a cardiologist who prescribed atenolol, lisinopril, a low dose aspirin, and Lipitor. His symptoms continued.

We called his primary physician again when he started trembling. At that time he told us to discontinue the lisinopril. The Lipitor was never started because we felt he had enough problems already without taking more medications. My husband then developed a hiccup spasm which is very loud and happens sporadically. He continued to have the extreme tiredness, lightheadedness, dizziness, and trembling so back to the doctor we went. An ultrasound of the carotid artery was ordered and was found to be clear, despite the fact that he nearly fell over after the exam. We were referred to an ear-nose-and-throat specialist to rule out a middle ear infection. Everything appeared to be fine but recommended to our personal physician that a test be done on the inner ear and an MRI of the ear and brain. We decided to hold off on the testing at that point.

In January 2008, our doctor prescribed an antidepressant, fluoxetine. His symptoms improved slightly but two weeks later, my husband couldn’t urinate and was sent to a urologist. He finally was able to go shortly after we arrived for the appointment. During the exam everything was found to be normal but it was recommend that he have an internal exam of his bladder. That test was never done.

Back when my husband had the cough, he felt something happen in his lower torso but didn’t notice anything. He then developed a bulge in late January 2008 that was diagnosed as a hernia. By the time this arrives to you he will probably have had corrective surgery (scheduled for May 2008). He continues to have symptoms despite stopping most of his medications and now has trouble urinating, constipation and a hernia. We don’t know what to do, his doctors cannot find anything wrong and I am worried.

DEAR READER:
Your husband appears to have a series of seemingly unrelated symptoms. Some are similar to adverse effects of his medications, others of vertigo, infection and his hernia.

Your husband’s doctors appear to have done appropriate testing and exams but thus far have failed to find an explanation. Therefore, I recommend your husband get a second opinion from another internist who specializes in ailments of the whole body rather than just this part or that part. You should bring a copy of your husband’s medical record with you to the appointment which will provide an accurate history of symptoms, medications, testing and more. Perhaps having a fresh set of eyes look over the history and do another general examination will reveal something overlooked.

As for holding off on the testing, I urge you to now have that MRI of the ear and brain. The dizziness, lightheadedness and nausea may all stem from vertigo. Vertigo is caused by an abnormality within the ear that can, often upon waking, looking up, bending down and more can cause motion sickness-like symptoms.

The constipation, inability or difficulty to urinate may be part of the hernia which once repaired should stop symptoms. A hernia occurs when part of the intestine slips through an abnormal hole in the abdomen into various areas. Depending on the area of the hernia, symptoms vary. Constipation is fairly common because the stool within the bowel can become blocked in the area that has been “misplaced”. If the intestine is pushing on the tubes leading from the kidneys or the bladder, urination can be affected.

Get a second opinion and follow-up on the recommended testing. Let me know how this turns out.