End to surgery?

Some doctors are waiting to see if their patients develop a life-threatening complication. When Shamus Burns found a lump in his groin on holiday last year, he was naturally alarmed.

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But after seeing a GP on his return home, the year-old Huddersfield University lecturer was reassured to learn it was just a small hernia.

Hernias – either in the groin or abdomen – are very common, with around a quarter of men affected compared with just 3 per cent of women.

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Indeed, hernia repair is one of the most commonly performed operations in the UK, with more thancarried out each year. While hernias can be symptom free, many men suffer severe discomfort and pain.

And, although rare, there is a risk of an untreated hernia becoming ‘strangulated’, where the intestine becomes so firmly wedged in the abdominal muscle that its blood supply is cut off, which can be life threatening.

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Although he was told this was highly unlikely in his case, Shamus was offered surgery to repair the hernia. However, many thousands of men will no longer have this option, due to a radical – and controversial – shift in the approach to hernia treatment.

Instead of routinely operating, consultants in six regional health authorities are adopting a policy of ‘watchful waiting’.

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This means patients are advised to return to their GP only if they have symptoms typically pain or the hernia grows. The change is in the wake of recent American research that showed monitoring patients, instead of them having immediate elective surgery, did not raise the risk of a strangulated hernia.

Supporters of watchful waiting also point to the fact that in up to 20 per cent of cases, the hernia recurs where surgery is carried out.

Furthermore, there can be debilitating side-effects.

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A study at the University of Aberdeen found that around a third of patients reported chronic pain after their hernia operation.

The problem of post-operative hernia pain is so ubiquitous that it has earned an official label: Post Herniorrhaphy Pain Syndrome PHPS – ranging from tenderness at the site of the surgery to chronic debilitating pain and back ache.

He himself has lived with two hernias – ‘one on the right, one on the left, had them for 20 years, both symptom-free’ – that he’s never had treated or repaired.

As he explains: ‘Having been a surgeon for many years, I know the operation does not always go well.

Personally, I’m not interested in exchanging a painless state for a 15 to 20 per cent chance of ongoing post-operative pain. Four years ago, the Department of Health asked Professor Meakins to write a list of criteria for hernia surgery.

He concluded that repair should be offered only when the hernia is painful and growing; where the patient has a history of complications; where the patient’s job is dependent on the repair, or if the patient demands it.

In fact, as Professor Meakins points out, the latter rarely occurs. He believes repair is only necessary for younger men who play a lot of sport, have an active job, or feel, due to discomfort or embarrassment, that their hernia is affecting their love lives.

But the shift to watchful waiting has angered some who believe hernia repair is being dropped simply to save money.

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Professor Meakins agrees that saving money was ‘almost certainly’ the original motive for the move away from surgery.

But that, he suggests, is not a bad thing.

Mark Woods would vehemently disagree. For the year-old supermarket worker from Tonbridge, Kent, the policy of watchful waiting has been painful and – in his view – unnecessary.

He first developed a hernia inand underwent surgery to repair it. Then, late last year, he began to experience swelling in his groin again – another hernia was developing.

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This time he’s being treated with watchful waiting. Mark says the pain has been so bad that he’s had to take eight weeks off work.

Since then my consultant has told me he wants to see if it enlarges before he arranges an operation. I know the operation carries a risk, but I’m still desperate to have it so I can get back to normal.

I want my life back,’ he says.

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The fact is, most hernias are painful and should be treated, says one of the world’s leading hernia experts. For this reason, we also recommend repair for patients with minor symptoms as long as they are medically fit for a local anaesthetic’.

He has spent most of his career in medical research, and says: ‘As a scientist, I read all the original research papers on watchful waiting and they were excellent.

While there was no benefit in the majority of cases from operating, the risks of post-operative pain were relatively high.

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Yes, I feel occasional throbs of pain, but as we age, who doesn’t? This keeps the hernia pushed back in place, behind the abdominal muscles, while the muscle wall has a chance to heal itself.

If it were to become strangulated, I am sure emergency treatment would be successful. Why are men being refused surgery for their hernias? Share this article Share.

Watch and wait: Shamus Burns turned down a chance for hernia repair.

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