Pax Inguinalis (Part 2)

Together, we, the working surgeons of the world, will institute the Pax Inguinalis, a just and equitable anatomic peace that will eliminate the burden of post hernia repair pain syndromes. As chief negotiator, I embark on this effort without weighty professorial or academic credentials. The hallmark of my curriculum vitae is a 40-year membership in the Automobile Club of Southern California, as well as a rather well-received after-dinner speech in Morristown, New Jersey in 2002. I have never published scientific papers on inguinal hernia repair. I have no academic rank or surgical prestige.

I have never opined on when the transversus abdominis becomes aponeurotic, although I dated a woman once who became aponeurotic during an anti-war rally in Chicago in 1971. But that's for another essay. I have eschewed the faculty lounge, the breakout session, and the focus group. I once, however, had a brief liaison with a facilitator. Because I lack academic gravitas, I am doubly honored to have been chosen from the surgical rank and file to serve as chief negotiator.

My single qualification for moderating the negotiations for the Pax Inguinalis is that I have performed a lot of hernia repairs. I have also been confronted with just about every conceivable complication of this operation. In addition, I have chaired many conference reviews of complications of hernia repair. Many of these complications arose after what I thought had been well-performed surgical procedures. But any experienced surgeon realizes that complications can occur after even well-performed procedures. Surgery is biology. Surgery is not chemistry. Every time one mixes oxygen and hydrogen under the proper circumstances, one will get water.

Not so in surgery, where every time a well-performed hernia repair is carried out, perfection does not necessarily ensue. I repaired a right inguinal hernia on Sid Rosenthal. Sid Rosenthal's testicle became a grapefruit. I repaired Maury Klein's recurrent left inguinal hernia. Maury Klein's hernia recurred.

Phil Fleiber's hematoma took two months to resolve. Sylvia Plathman-Nirdlinger's left labium majus was numb for six months. Kyle Fuhrman's testicle atrophied after repair of a recurrent hernia three months before his wedding. And I have not even mentioned Jan Klosterman's year-long John Wayne gait. I have traveled down that canal.

In addition to a litany of my own post-operative problems, I have also seen many patients in second opinion consultation. I have seen these patients on a pre-operative visit and in second opinion during a post-operative visit. But even recognizing the potential complications of this procedure, I continue to enjoy the surgical challenge of hernia repair. I have discussed all these aspects of repair for many years with a group of well-educated and experienced colleagues. These comments and insights have not been published as tracts in Acta Herniographica Scandinavica or even in annals of herniology.

They have not been subjected to the Kaplan-Meier regression analysis. They have not been scrutinized by an institutional review board committee. My observations have weathered the unyielding tripartite crucible of the surgeon's lounge, the physician's dining area, and legions of inquisitive and sometimes quite annoying surgical residents prior to their commencing laudable careers in dermatology. Inguinal hernia repair, and I limit my comments here to standard, inguinal hernia repair, is a marvelous exercise in anatomic precision, human embryology, surgical history, and operative technique. When I gaze at the freshly-shaven, inguinal region laid bare after the timeout, review of the surgical team's tuberculin test status, checklist, operating theater code of conduct, conflict of interest, disclaimer, and underwriter's laboratory history of the electrocautery unit, I think of, and will express to any resident permitted to be present by work hour requirements, the following issues and insights.

One, what life events has this inguinal region experienced? Two, who was president of the United States when this inguinal region was created? Three, did this inguinal region ever see military combat? Four, does this region realize that it houses Hesselbach's triangle, Tisdale's trapezoid, the dorodecahedron of de Monde, Onan's octagon, a processus vaginalis and vaginalis, filamentous cremaster fibers, and a pampiniform plexus. Why is the plexus called pampiniform?

This will be covered in a breakout session on day two. Five, does this inguinal region realize that despite strict zoning laws, that it lives close to at least 17 other tubercles? Six, who came through this vas deferens? Who was supported by this round ligament? Whatever happened to these individuals?

Seven, has this inguinal area ever been swimming in Lake Winnipesaukee in early June and been surprised by a vigorous dartos reflex? Eight, where was this inguinal area when the Red Sox won the World Series? Nine, where was this inguinal area when the Cubs won the World Series? Ten, is this inguinal region aware of Maimonides' seminal text on the descent of the Kishkis? All parties at the negotiating table understand our initial task for a just and lasting peace in the inguinal region begins with a discussion of the issues that arise before the operation.

And it is on this front where my formidable negotiating skills will bring together two warring surgical camps. Stay tuned for part 3, where I discuss whether the benefits of the repair outweigh the risks of the repair.