Hernias: A Pain in the Groin

What Exactly Is A Hernia?

Your abdominal cavity is surrounded by muscles which keep all the internal organs from falling out. In the back, the muscles of the spine are thick and strong but on the front the muscles are thinner. At the upper part of your abdomen, the diaphragm separates your abdomen from your chest.

You’d experience a hernia if there is a weakness or rupture of part of this muscular wall. Basically, a hole forms in the muscular wall of your abdomen.

Some of the contents of your abdomen may protrude through this hole. It can be some fat but it can also include your bowel.

Abdominal wall muscles
Abdominal wall muscles
Your Lump Is A Hole!

From the outside, you may see a lump but that lump is in fact a hole!

In the early stages, the lump may come and go. When you lie down, the contents return to your main abdominal cavity so the lump “disappears” only to return when you stand up or cough.

At a later stage, your lump may become stuck and remain visible even when you are lying down.

Hernias are more common in men and occur in the groin (called an “inguinal hernia”). An inguinal hernia starts as a lump in the groin but if large, it can fill the whole scrotum. It can also occur in a previous abdominal wound due to poor healing (incisional hernia). Other areas for hernias to appear include the umbilicus (umbilical hernia), lower groin (femoral hernia) or diaphragm (diaphragmatic hernia).

Inguinal (groin) hernia
Inguinal (groin) hernia
Are Hernias Dangerous?

Generally, no although they can cause discomfort and pain. If your bowel protrudes and gets trapped in the hernia, it may become obstructed. Your bowel will then swell and may go gangrenous if the blood supply is cut off. If that happens, it becomes a surgical emergency and needs an immediate operation to avoid rupture or perforation of the bowel.

Can Hernias Be Prevented?
Bowel protruding through a hernia in the abdominal muscles
Bowel protruding through a hernia in the abdominal muscles

Hernias are caused by excessive muscular straining which is associated with heavy lifting or persistent coughing.

Footballers often get a hernia. If you are overweight with weak abdominal muscles. you may be at risk of getting a hernia. If you have had previous abdominal surgery and the wound has not healed well, you may also get a hernia. Possible causes include previous wound infection, obesity and thin weak abdominal muscles (such as in the elderly).

  • Lose weight!
  • Avoid heavy lifting or strenuous activity
  • Keep your bowels regular, avoid constipation and straining too hard
  • Stop smoking! All smokers cough!
Treatment for Hernias

If you have a hernia, you need surgery to repair your hernia.

In the past, if you had a defect in your muscle, the surgeon would repair this defect with sutures or stitching. But this can lead to re-occurrence of your hernia if the sutures or stitches tear out of the muscle, especially if your muscles are weak to begin with.

You have a better option today.

As surgeons, we now use a special plastic mesh to cover up the hole and the mesh stays permanently.

Mesh repairs have a much higher success rate compared with the older method of using sutures. Scar tissue grows into the mesh (made from polypropylene, a sturdy and strong type of plastic) adhering the mesh firmly to your surrounding muscle. A skilful surgeon will have no problems inserting the mesh into the right place.

What’s even better is that the mesh can be inserted using laparoscopic surgery or keyhole surgery. We simply roll up the mesh and stick it in! This method results in faster healing, smaller scars and less pain.

If you come for a hernia surgery, I suggest you consider using laparoscopic surgery for your hernia repair.

Will My Hernia Come Back Again?

It is possible but not common for hernias to recur if a proper mesh repair has been done.

My own personal results was 1 case of recurrence out of a series of over 300 repairs – that is 99.7% success and only 0.3% recurrence.

Of course, if you get an inguinal hernia, you could still get a hernia on the other side if you continue to do heavy lifting or straining!

All You Ever Wanted to Know about Gallstones

What Is The Gallbladder?

Your gall bladder is an organ that sits under your liver on the upper right part of your abdomen. It stores and concentrates bile from the liver. While the gallbladder contains bile, it does not actually make bile – that is done by the liver.

Bile is necessary for the absorption of fat in our diet – rather like soap, it allows fat to mix with water making it easier to absorb from the small bowel.

Whenever we eat a meal rich in fat, our gallbladders contract, squirting out a small amount of bile into the small bowel to aid digestion.

Diagram of the gall bladder and organs around the gall bladder
Location of gallbladder (liver partly cut away)
How Then Do Gallstones Form?

Gallstones form when the bile has become too concentrated.

It is like thick soya sauce which has been kept in the fridge for too long – it solidifies and forms crystals.

Initially, the gallstones are small, like sand, but over time they can grow quite big. The largest stone I have removed via surgery was about 5cm long.

How Do I Know If I Have Gallstones?

Here are some common symptoms if you have gallstones. Symptoms can also vary, depending on where the stone is.

  • Jaundice (where your skin and eyes turn yellow)
  • Nausea & vomiting
  • Upper abdominal discomfort when you eat fatty food (fat intolerance)
  • Flatulance (wind, belching)
  • Upper abdominal pain (centre and right upper abdomen)
  • Fever

On a positive point, although gallstones are common, not all cause trouble.

Typically you will have pain because the gallstone gets stuck at the narrow part or neck of the gallbladder. Whenever you eat a fatty or rich meal, the gall bladder contracts but the opening is blocked. It’s like pushing against a closed door.

When this happens, you feel pain. This pain is usually felt in the upper part of the abdomen in the centre or to the right under the ribcage.

If your gallstone gets well and truly stuck at the neck of the gallbladder, the gallbladder becomes inflamed, red and swollen.  It may become infected so you may have a high fever along with the pain. You may feel a tender mass in your upper abdomen. This is known as cholecystitis.

If you don’t get it treated, your gallbladder can become gangrenous and even perforate. Sometimes, if the gallstone is large and erodes its way into your small bowel, the gallstone can block the small bowel. This is known as “gallstone ileus”.

If your gallstones are small, they may pass into the common bile duct. There, they may obstruct the common bile duct and block the flow of bile from the liver into the small bowel. This causes jaundice where your skin and eyes turn yellow and your stools may become pale and float.  Jaundice is always potentially serious and if you have jaundice, you should see a doctor immediately.

If the obstructed bile becomes infected, you will develop a high fever with the jaundice. This could lead to septicaemia (infection in the bloodstream) which is a serious and dangerous condition.

If the stone gets stuck at the lower end of the common bile duct close to the pancreatic duct, the surrounding inflammation could block the pancreatic duct as well leading to a condition called acute pancreatitis. Acute pancreatitis is a serious disease that can result in multi organ failure and death.

Will Large Gallstones Cause More Problems Than Small Gallstones?

Size is NOT the cause of the severity of pain from having gallstones. Large stones tend to cause inflammation and block the gall bladder. Small stones slip out but are more likely to get stuck at the common bile duct causing jaundice.

Pain caused by gallstones can be severe – some patients report that it is the worst pain they have ever had.

I Suspect I Might Have Gallstones. What Do I Do?

If you think you may have gallstones, contact me and I can arrange for you to take some tests such as an ultrasound scan of the abdomen and some blood tests. You may also have your abdomen scanned.

I Have Gallstones. What Should I Do Now?

If your gallstones are causing symptoms, I recommend that you remove them, together with the gallbladder. This can be done with keyhole surgery and it is specifically called laparoscopic cholecystectomy.

91% of all my patients’ gallbladder operations are done this way.

You’ll be assessed (with additional tests or procedures) before we progress to surgery. If your gallstones have already caused acute pancreatitis, we may want to let the inflammation in the pancreas settle down before surgery.

Why Can’t We Remove Just The Gallstones?
Why Must We Remove The Gallbladder Too?

The stones are inanimate and sit in the gallbladder or bile ducts. They do not become painful by themselves (because they have no nerve supply) but they cause the gallbladder to become painful. Removing just the stones therefore may not get rid of the problem. Besides, the gallbladder is the stone factory – picking out the stones and leaving the factory behind is inviting further trouble in future when more stones form!

Sometimes there are hundreds of tiny gallstones like sand. It is impossible to pick these up one by one. If stones spill out and fall between the loops of your small bowel, it becomes difficult to find and remove all the stones.

Based on these reasons, if you have gallstones, the recommended (as well as recognised and accepted) treatment is to remove the entire gallbladder with the stones inside using a method we call laparoscopic cholecystectomy.

Will I Still Be Able To Live Healthily Without A Gallbladder?

After we remove the gallbladder, you will still be able to eat and digest food normally, including fatty food (though of course too much fat is also not good for the heart amongst other things!). You do not need to restrict your diet or activity.

The gallbladder does not produce bile – that is produced by the liver. It merely stores and concentrates the bile. Like the appendix, it is present in your body but it is not 100% needed.

Some patients may notice their stools become softer after their gallbladder operation. In general, if done properly, you will have very few problems after gallbladder removal.

Can We Dissolve Gallstones With Medication?

This won’t work on all types of gallstones. Medication works best if you have cholesterol stones. Even so, medication does take a longer time to work and it is hardly ever used now to treat gallstones.

Cancer In The Colon

Madam T was a 78 year old Chinese lady who was referred to me with blood in her stools. She also had diabetes, high blood pressure and had previously suffered a stroke.

When I met her, I advised her to undergo a colonoscopy.  During this procedure I found she had small polyps in her rectum and left colon which I removed with the colonoscope.

However, this was not the last of her problems.

Cancer In The Colon

The colonoscopy also showed a cancer of the left colon as well as a huge polyp in the right colon which looked very suspicious. The right colon polyp was too large to remove safely with the colonoscope and could only be removed surgically.

colon cancer and polyp removal
Madam T’s Colon Cancer and Polyp

I decided to do a CT scan of the chest, abdomen and pelvis just to be sure the cancer had not spread elsewhere.

As polyps can become cancerous over time, I could not leave the polyp alone especially as she had already developed a cancer in the left colon.

To remove the cancer in the left colon as well as the polyp on the opposite side, undergoing open surgery would have meant a long incision from the upper to lower abdomen.

I recommended laparoscopic surgery as this would mean a much smaller scar, less pain and faster healing. Nevertheless, the operation still had some risks due to her age, diabetes, high blood pressure and previous stroke.

She was also on blood thinning medication (antiplatelet drugs) which would increase the risk of bleeding during surgery.

But the biggest obstacle was yet to come.

She Refused Surgery

Madam T was completely against surgery. She was understandably worried and frightened.

She firmly refused surgery although I told her that this could be an early cancer. Her best hope was to remove the cancer through surgery. Untreated, it would most certainly progress, possibly to obstruction or spread elsewhere beyond the reach of any medical help.

Sensing her fear, I decided to keep my silence as I completed her tests including a thorough cardiac assessment.

Finally, I drew her family aside and explained the situation clearly to them. Yes, there were risks including leaks, bleeding and another stroke.

No, I could not promise to deliver an operation without complications but I did promise I would leave no stone unturned and would try my very best to make it as safe as humanly possible. It helped that the daughter had seen me as a patient on an earlier occasion and I had already won her trust.

Madam T finally agreed to proceed after much cajoling from her family, signing the consent form dejectedly.

The laparoscopic surgery was a success. We managed to remove both the cancer and polyp using just a 6 cm long incision. During the operation, we noticed there was no visible spread of the cancer which was a relief!

Soon after, Madam T had a good recovery post-operation without any complications. She was relieved that her surgery went well and was glad she was persuaded to undergo it, despite her earlier misgivings.

She is presently on chemotherapy and there are presently no signs of recurrent cancer.

Gallstones And Gangrenous Gallbladder

From time to time I will share some of my more difficult cases so that you understand what happens during surgery.

The case below involved a Chinese man in his 60s who suffered from gallstones and an inflamed gallbladder.

Mr C, a 61 year old Chinese man came to see me with right upper abdominal pain and high fever. When I did an ultrasound scan of the abdomen, I noted that the scan showed large gallstones and an inflamed gall bladder.

gallbladder-inflamed
An inflamed gallbladder

After a careful preoperative assessment, I advised him that he needed a laparoscopic cholecystectomy.

During the operation, the gallbladder was badly inflamed and had started to become gangrenous. What made it more challenging was that the gallbladder was stuck to the surrounding tissues making surgery difficult.

The gallbladder wall oozed pus and we found a fairly large gallstone jammed into the neck of the gall bladder!

While it was rather challenging, we finally managed to carefully dissect and remove the gallbladder laparoscopically without conversion to an open procedure. This is always good news for the patient as laparascopic surgery possesses many more benefits compared to open surgery.

I am happy to report the laparoscopic surgery did Mr C a world of good. He recovered well from his operation without any complications.

Pregnant Mother With Perforated Appendix

When Madam A, a 24 year old lady from Indonesia, came to see me, she suffered from pain in the lower abdomen.

She had been having fever, pain and diarrhoea for the past 2 weeks. She was also 10 weeks pregnant.

I decided to quickly proceed with an ultrasound scan of her abdomen to find out the cause. The scan showed her 10 week old pregnancy with a large 14 cm abscess in the pelvis due to a perforated appendix.

Clearly, surgery was necessary.

But here’s the thing –  if she underwent an open surgery, she would have required laparotomy (long midline incision) which would have left her with a large lower abdominal wound.

This would then be a potentially weak area in her abdominal wall. As her pregnancy advanced, there would be a risk of developing a hernia or rupture of the laparotomy wound. Furthermore, a large abdominal wound would also make it more and more uncomfortable later in pregnancy.

She was quite worried. As all expecting mothers go, she was clearly worried about the risk of surgery to her unborn child.
I recommended that we try a laparoscopic approach first and if that did not work out as well as it should, we might have to go with an open procedure or open surgery.

While an operation sounds easy, it isn’t always the case. Every operation is a challenge on its own.

And this was one of my most difficult laparoscopic appendicectomies.

The womb was much larger than normal and was sitting just next to the abscess. It had to be handled with extreme care, if at all.

We discovered a large abscess full of pus in the pelvis in front of the uterus. The appendix had ruptured and disintegrated. After a lengthy and careful dissection, we found and removed the remnants of the shattered appendix and drained the abscess cavity of pus.

Madam A made a slow but steady recovery after the surgery. She went home to Indonesia when she was well enough to travel.

She happily reported that her pregnancy proceeded without further complication and she gave birth to a healthy baby 6 months later.