Hernia 101 help in ZH?

Family, Education, Health and Pets
1
I coughed hard in my sleep many months ago and felt a very sharp pain in my lower left abdomen region. Then no real pain. To be safe, I visited my GP, and he tested with ultrasound and said all ok and that I probably had a minor muscle strain due to hard coughing. I continued fitness training like I have done for decades.

Since the cough episode, a low 1 out of 10 pain persisted on my left side. I went back to my GP, he could not find anything.

I decided to get a second opinion, so visited an ultrasound specialist, well he diagnosed me as having Inguinal hernia on both sides! The left painful side has a tiny hernia, and the right side with 0 pain has a large one Externally, there is no sign on either side, I mean, not even a tiny bulge anywhere. I do have a six-pack and a very strong core, so maybe that is keeping it suppressed compared to someone who is overweight?

The ultrasound doctor was a man of few words, and he does not deal with treatment, so he was not really interested in talking with me. Just said you have to operate, and before I could speak more, he ran away. The report passed to my GP and I got a copy by email as my GP had specified that I get a copy.

My GP has given me the option to find any surgeon. Now I have been digging deep on the subject and even though it is supposed to be a "minor" surgery, it is a bit of a minefield with regards to different schools of thought.

Mesh insertion via 3 holes is the obvious surgery I thought, but apparently a plastic mesh is not all that it has been cracked out to be. Repair with your own natural tissue when performed by an experienced surgeon can give better long term outcome???

Some negative points about mesh that I have come across-

- Foreign body reaction.

- Movement of the mesh.

- Mesh shrinkage.

- Mesh adherence to surrounding tissue, nerves and organs.

- Nerve entrapment or ingrowth in the mesh lattice.

- Mesh fibres eroding over time and penetrating intestines, bladder, vas deferens or other vascular structures.

- Chronic inflammation of tissues caused by the foreign body reaction and scarring.

- Sex related pain.

- Hernia recurrence due to hardening of mesh over time.

- New Hernia at the 3 incision points

- Mesh related infection. Removal of mesh very complicated as it fuses with biological matter and can't be simply peeled away.

- Greater risk with keyhole surgery for Hernia operations.

- Full anaesthesia.

I am a fitness fanatic. I am really lost now! Really need to find an experienced surgeon who I can speak with and discuss my specific case. I know in the greater scheme of things, it might not be the end of the world, but I do have to make educated choices. Specially as I have on both bloody sides!!!! Double trouble?

My GP mentioned someone in Tremli Hospital, and a forum search revealed someone in Hirslanden Klinik. Any of you had this surgery who still managed to have a VERY active lifestyle post operation? Any input would be greatly appreciated

2
I've had 2 inguinal hernias (one on either side) and 1 femoral hernia.

1st inguinal hernia repair was done at St Mary's in Paddington. Surgical cut was made and Mesh was used. Hernia was massive and painless, had it for years before repair. Recovery was a couple of weeks, mesh took some time to settle.

2nd inguinal hernia was done at St John and Lizzie's in St John's Wood. Surgical cut was made and Mesh was used. Hernia was pea-sized and incredibly painful. Was told that the smaller hernias tend to be the most painful. Recovery was a couple of weeks, mesh took less time to settle.

3rd femoral hernia repair was done at Andreas Clinik in Cham, Zug. Previous cut was opened and reused, Mesh was replaced. Hernia was small and relatively painful. Recovery was a couple of weeks and I was back doing Pilates and cycling within a month.

Mesh is the way, it'll never tear and I'm not sure you'll even be given an option. If you have keyhole surgery you'll recover even quicker and will be back to your active lifestyle quickly, don't worry.

3
I had an inguinal hernia. The only symptom was a mild itch in the groin. Fixed with a mesh via laproscopic surgery. No lifting more than 15kg for three weeks.

Never had an issue. The worst part was the post-op morphine. Horrible stuff - I told them not to give me any...

Bear in mind that if it isn't repaired, you could end up with a strangulated hernia which is life threatening and could permanently end your fitness regime.

4
Ouuch! May I ask how many years ago you were operated? What age range are you in?

Was there a specific incident that caused it, or was it just gradual weakening and breaking down of connective tissue, fascia etc over time? I assume the latter?

Yes, I hear you 100% about mesh, but a lot of sporty types have suggested going natural tissue repair way if the adjacent tissue is in good condition. If not, then mesh is the only option anyway. Even if the mesh does not break, it seems it won't remain flexible in coming years. The long term prognosis of plastic mesh is a bit mixed. I am just researching, so I am prepared when I meet the surgeon.

People keep pointing me to "Shouldice" procedure?

My 2 out of 10 level pain is 1 finger to the left of belly button and 45 degrees downwards, seems far from groin. Although it has been clearly classed as inguinal hernia in the report. How long ago were you operated?

Yes, I will definitely operate asap! This year hopefully.

Someone asked me to find out the actual size of my larger non-painful right side hernia as the report did not mention the size. I shot an email to the ultrasound place about the size and the doc is on holiday, but replied that they forgot to mention in the report that-

"...intestine is in the content of the sac. That's more important."

Does that make it more urgent?

5
It isn’t going to be flexible either way, because there is going to be scarring. In the case of the mesh, your body is going to wall it off, hardening the mesh scaffold. In the case of the simple sewing together of tissue, that will also lead to scar tissue formation along the suture, which will also be hard and inflexible.

Even if the adjacent tissue is able to be sewn back together, the size and location of the hernia may preclude a simple fix. Remember that this repair has to hold up against the pressure of your internal organs pushing on it; not just weeks later, but also directly after surgery. If the suture is too big, the weight of the organs may overwhelm what the stitches are able to hold.

This is a clinic in Toronto which specializes in hernia repairs; that’s all they do. They pioneered their own procedure for doing them and have a great success rate.

However, your surgeon may or may not have done many of that particular protocol. In the hands of a less skilled surgeon (at that particular protocol) the success rate of the hernia repair would be expected to be lower than that achieved in Toronto. So take the Shouldice success rate with a grain of salt.

And while an ‘open’ laporotic procedure may repair the sac from the outside, so that you don’t penetrate the sac tissue that you are trying to repair, I’m not sure that I would call it less invasive. You still need to make a bigger hole through the skin and muscles in order to access the peritoneal sac. I’ve recently had both laporoscopic and laporotic surgeries and the latter took much longer to recover from than the former, with increased need for pain management, simply because of the scale of the incisions.

No, less urgent. It means that your intestines are where they should be inside the sac instead of peeking out of the hernia where they can get strangulated, causing urgent critical problems with blood flow and intestinal function.

Do come back and let us know how you got on with the doc.

6
An old friend of mine had it done in Hirslanden with a top specialist in Zurich, name escapes me at the moment; but your GP should know and refer you. If you have private or semi- private insurance, the availability of the private clinics should not be a problem.

Anyhow he was mid 50s, very fit and sporty, and same concerns going in as you as he did not want complications that could hinder sports and private man stuff. He had 3 keyhole with mesh. Absolutely no problems and felt much better afterward, seems hernia was inhibiting his sports more than thought before. He recovered much faster than the norm and Dr attributed that to his active sporty lifestyle.

7
Tox_Rat, thanks for such a long and detailed reply. I really appreciated you taking the time. In the last 2 days, I have researched the subject to death!

Hmm, I was thinking the opposite, you might be right though, but I can give you better context (taken from my ultrasound report)-

Inguinal canal:

On the right side - Closed femoral portal but a surprisingly large hernial sac formation inguinal, into which flap tissue can be squeezed out completely symptom-free under Valsalva manoeuvre (Valsalva manoeuvre- Nose and mouth closed while I was blowing air).

On the left side - Findings are clearly less pronounced, but a hernia sac seems to be developing here as well. The femoral orifice is also closed on the left side.

This below part was sent by the ultrasound place via email when I enquired about the dimensions (I have no idea which side he means or maybe both) -

8
My GP has left it to me and will refer me to anyone I want. He did mention someone in Tremli hospital, but I am not confident about my GP any more. My GP had given me the all clear after he himself checked me via ultrasound. I trained hard for the next 6-7 months because I wrongly trusted his findings.

I have basic Sanitas insurance, but the type that allows me to choose any doctor in any Kanton. From what I understand, Hirslanden will take me. I am not rich, but I rather go with an excellent surgeon, even if I have to pay extra on top or take semi private insurance. I keep hearing from people that the surgeon is very important for having a better longterm outcome.

Good to know. The hernia was not hindering me in any way, as until 2 days ago I did not even know that I had it, let alone on both sides! There is no bump or bulge anywhere.

9
To summarize, you should get these 2 hernias taken care of, but the situation is not immediately life threatening. Otherwise, he’s describing the findings for the surgeon to know what specifically you have. Together with any images, your surgeon will use the report to recommend a specific procedure. Size does matter, but in the sense that it would be one of the factors the surgeon would use to make his recommendation. In the sense that the technician is using when emailing you, (s)he’s telling you not to worry about it, as both hernias will be repaired just fine, no matter how big a mesh is needed.

A good surgeon is important, but the care and surgeons available to you under basic healthcare in Switzerland, e.g. at a cantonal hospital can be better than the ones in the private hospitals. Also what you have isn’t particularly exotic, so good-enough may be good enough; you probably don’t need the skills of the world’s expert. Nonetheless, it is an open secret in Switzerland that when the private hospitals get into trouble, the patient is transferred to the cantonal hospitals, because that’s where the expertise is. Several Swiss cantonal hospitals are consistently ranked in the top-20-hospitals-in-the-world lists.

Healthcare here is expensive; surgeries cost 1000s-10’000s. Get an approximate quote before you decide on Hirslanden. Your idea of taking out semi-private insurance won’t fly now that you have a diagnosis, so you will be on the hook for all of it, even any unforeseen complications. Were it me, I would just ask my GP for a recommendation for the best hernia surgeon at either my local cantonal hospital, or a neighboring one which is highly rated in one of those googlable lists. (You are going to have several appointments there, you might as well make it easy to get to.)

10
Tox_Rat,

My GP did not recommend anyone confidently, he mentioned one surgeon at Triemli, but his wording was, "he seems good" , plus that he will have long waiting time. I am already in that chain so will at least meet the surgeon depending on when they get back to me.

I have another acquaintance whose father had it done at Unispital ZH, and it seems a trainee surgeon operated and did a bad job with the mesh placement etc. He had to be re-operated at Balgrist Hospital, the surgeon there fixed it, but was not happy about it all.

I hear it multiple times that the best operation for Hernia is the one done perfectly the first time. I understand it is not a complex heart surgery, but I have had a rotten run in the last few years with incompetent medical personnel, so I try to be extra careful.

Furthermore, I am also in the middle of some other issue that might or might not be autoimmune in nature, if it is then it could cause issues with the mesh. So I am on the edge a bit.

11
Update- Might be useful for someone in the future!

I called my health insurance, Sanitas. I have basic health insurance (can choose my own doc anywhere in CH) and some sort of supplementary insurance called- a) Classic + b) Hospital Standard Liberty.

Sanitas said that they will cover Hirslanden basic stuff, as they will have to pay similar amount to Kantonal Hospital anyway. Plus, Hirslanden are also a partner hospital.

The lady also said that my supplementary insurance gives me the choice to go in as basic OR semi-private/full-private patient, if I wanted to. The difference between basic and private will come out of my own pocket. Which is fine for me, but I don't see any point for private extras. All I want is a good surgeon and a place that does not leave me hanging if anything goes wrong.

I have narrowed it down to 3 surgeons, 2 have their own private clinic but operate out of Hirslanden. The 3rd is from Tremli Kantonalspital. My GP has set the ball rolling for the Kantonalspital guy. Based on what my GP said, I feel that the Tremli appointment will take a long time to come.

I will next re-contact Hirslanden as the surgeon(s) are on holiday. Ideally I want this done asap!

12

Just a follow-up.

While it looks like I will be getting mesh repair (meeting the surgeon next week). I would be lying if I say that the mesh repair does not bother me. I mean from an engineering mechanical sense it makes perfect sense having a mesh repair but from a long term biological sense, it makes me nervous.

Here is a recent BBC documentary on the subject-
3:15 to 5:00 mark is the most relevant part. 12 to 30% seems scary to me. That lady (Ulrike Muschaweck) is one of the top Hernia specialist/surgeon in Europe.

https://www.youtube.com/watch?v=MMGJvHGJcQY&t=205s

Then there is the Desarda Hernia Repair technique, invented by some Indian doctor. Seems like a really clever approach, although finding an experienced surgeon and if I am even a good candidate is another issue.

A cross-section scheme of the inguinal canal demonstrating the principles of Desarda repair: a narrow strip of external oblique aponeurosis (yellow) is moved onto a posterior wall of inguinal canal behind spermatic cord (green) and sutured to both the inguinal ligament and the internal oblique (blue). The anterior wall of the inguinal canal is closed with upper/medial flap of the external oblique aponeurosis (purple).