Diplomate, Board Certification of Emergency Medicine
Chairman, Department of Emergency Medicine Ma'ayenei Hayeshua
Hospital
One of my readers, Dr. Joel Gorman, offered to help me by
answering a question that a reader once wrote concerning
hernias. Dr. Gorman is a specialist in hernia surgery and
takes a lot pains to make sure he knows the most updated
information. Furthermore, he is a ben Torah and a
wonderful individual. I thank Dr. Gorman for his help in
writing this column, and wish him much success in his
avodas hakodesh in helping people.
First, I would like to thank Dr. Liebman for the honor of
being his guest this week.
Among the many attributes of Hashem's creation of human
beings is the ability to carry with us wherever we go a
liver, stomach, several meters of small intestine, a bulky
large intestine, as well as a spleen, two kidneys, and more.
This is done by a marvel of packaging. The organs are all
contained within a space called the "abdominal cavity" which
is surrounded by a hermetically sealed "wall" of strong
muscles in the front and around the flanks. Simply put, a
hernia is a defect in this muscular wall, through which the
abdominal organs, especially the intestines and the plentiful
intra-abdominal fat, can slip out. But of more importance,
the bulging organs can become incarcerated and even
strangulated by the ring-like defect in the living muscular
wall through which they protrude. I do not wish a hernia on
anyone. But if you suffer from one, it is probably one of the
following types:
First, the `groin': This is the region at the very bottom of
the abdominal cavity towards the front, just where each leg
starts. Hernias are common here in males and occasionally
occur in females, at any time in life. They may be caused in
adults by the same process which causes them in infants, a
slight imperfection during the development of the abdominal
wall in the fetus. However, wear and tear with age certainly
can contribute. According to this, the only way to avoid a
groin hernia is either not to be born, or never stand up and
be active! I do not think physical fitness affects the
occurrence or complication rate of hernias of the groin.
Second, a defect in the abdominal wall at the bellybutton
(umbilicus) is also common, but more so in females,
especially multigravid. As to the causes of umbilical
hernias, extreme overweight, as well as wear and tear, and
also birth defects of the umbilical region of the abdominal
wall, all contribute. Maintaining fitness throughout life and
avoiding obesity will help a lot to limit the development,
and perhaps even the occurrence of this hernia.
Less commonly, one may suffer from a defect at the point of a
previous incision in the abdominal wall; for example, after
appendectomy or caesarean section, or surprisingly, after one
or more attempts to repair a groin or umbilical hernia. The
cause of incisional hernia is an imperfection in the original
surgical technique.
As a surgeon who specializes in hernia surgery, my first
responsibility is to determine if a hernia exists, or not.
Happily, it very often does not, despite what you might
suspect or have been told. If it does, I believe the best for
you who suffer from a hernia is surgery. I recommend the
Abrahamson technique, sometimes with my modifications, which
is in experienced hands and with Hashem's help, guarantee
essentially 100% cure rate of groin hernias and umbilical
hernias, and close to 100% for the more difficult incisional
or recurrent hernias. The basis for my recommendation is
twenty years of experience with these techniques, learned
directly from their originator, and a scientific study of the
techniques including close, long-term follow-up of every one
of my patients.
In addition to the cure rate, the risks involved in surgery
are also an important consideration in recommending a
particular operation. For this reason too, I prefer the
various Abrahamson techniques for all types of hernias, since
they treat the defective abdominal wall itself without
requiring entrance into the abdominal cavity and involving
its organs. In this regard it is akin to plastic surgery.
This generally allows for the use of local or regional
(epidural or spinal) anesthesia, and assures a very short
hospitalization in essentially all cases. The overall result
with the judicial use of these techniques is a significant
reduction in serious complications. Also, many of my patients
are very overweight individuals; but boruch Hashem,
obesity does not seem to adversely affect the low
risk/high success rate of the Abrahamson techniques.
Finally, a word about a very special and sensitive problem:
Childbearing has profound effects on hernias of the abdominal
wall. There are special stresses and pressures on the
abdominal wall during pregnancy, which can cause an umbilical
hernia, or which can compound the risk of an umbilical hernia
already present. Also, a caesarean section is sometimes
required in pregnancy and this can result months later in an
incisional hernia.
Must these hernias interrupt the normal childbearing years?
Most surgeons and activists in the field advise in the
affirmative. They wrongly believe that if surgery is done,
subsequent childbearing may either ruin the surgical repair
of the hernia with the result that the patient will need to
suffer a recurrence of the hernia which is particularly
problematic or, if surgery is deferred, the woman will be
taking a clear health risk for herself and her fetus in
undergoing childbearing with an unrepaired, symptomatic
hernia.
For over a decade, I have offered couples in which the woman
is suffering from an umbilical or incisional hernia the
option of the modified Abrahamson repair. The results are
unique and gratifying, boruch Hashem, and have
recently been presented at an international surgical
conference in Toronto. Twenty-eight such couples have had 45
children after the hernia operation without a single
recurrence of the hernia. And one can hope these results will
only continue to grow.
Joel Gorman, M.D. Fellow, American Hernia Society.
Jerusalem Clinic - 02-5002226; Bnei Brak Clinic - 03-
5741424.
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