Pax Inguinalis (Part 3)

I will not regale the reader with a review of the technical aspects of hernia repair. They are available in any standard textbook of surgery written by men wearing 15-pound wing tips. One inguinal camp believes that every inguinal hernia should be repaired. These surgeons raise the specter of incarceration, bowel obstructions, emergency operations on Christmas Eve, and unsightly Speedo distortions. They equate inguinal distortion with the black death. The other camp believes that a hernia should not be repaired unless the hernia becomes symptomatic. The seminal question for both camps is, do the benefits of the repair outweigh the risks of the repair? Those who feel that every inguinal hernia should be repaired may say to the patient, it is a simple procedure. It is an in and out deal. You'll be back to full activity in 48 hours. The pro repair camp may accuse the no repair camp of surgical timidity. The no-repair camp may accuse the repair camp of knee-jerk surgical activity based on 1930 textbooks richly illustrated with men wheeling their scultitis-bound scrotum in wheelbarrows.

It is between these warring camps that I will serve as the mediator for purposes of instituting the Pax Inguinalis. The second negotiating session will be case-based. We will analyze a 43-year-old executive referred to a surgeon by a capable internist colleague, a colleague imbued with deep levels of refined cognition. The patient is fit and active. He has a small to moderate sized inguinal hernia. He has no symptoms. The following question will be the touchstone of hernia repair and will serve the basis of our negotiations. Does this hernia interfere with the patient's lifestyle? We are surgeons. We have become experts on lifestyle. Every grand rounds and major professorial and presidential address these days seems to be about the lifestyle of surgeons. So let us turn the tables a bit and ask about the patient's lifestyle since all of us are happy with our own.

Delegates to the conference will consider the value of these lifestyle questions. 1. Does the hernia interfere with the patient's daily activities? This question is predicated on a knowledge of those activities. This includes an analysis of the time-honored personal hobby list. Does the patient toss the caber? 2. Does the hernia interfere with the patient's work?

There is a marked difference between a stevedore, a ticket taker on a train, a librarian, or an aged pensioner the high point of whose day is sipping tea. 3. Has the hernia enlarged to the point at which the patient is the subject of ridicule, verbal harassment, and slander in a locker room setting? 4. Do crowds form on major boulevards as the patient walks down the street?

Are these crowds staring at the patient's inguinal region? 5. Does the hernia interfere with the patient's involvement with or enjoyment of intimate relations? 6. Does the hernia interfere with exercise?

7. Is the hernia perceived by the patient as an explanation for pain or symptoms unrelated to the hernia? 8. Has a photo of the hernia ever appeared on the internet? The committee will then consider the relationship between the presence of a hernia and the patient's complaints.

For example, every time I eat Guatemalan food, I get a burning in my stomach. Do you think the hernia is causing this? Every time I bend over, I get a pain in my back that shoots down to my great toe, then over to the other foot, travels up behind my knee then goes to an area behind my left eye. The astute surgical clinician will realize that such complaints are usually unrelated to the hernia. Exercising the privilege of negotiator-in-chief, I digress to tell the conclave that several years ago, I saw a young actress in surgical consultation.

She was a rising star in the adult film industry. A detailed history, including a peer-reviewed assessment of her past performances, convinced me that she was being denied leading roles because of an unsightly femoral hernia. I was convinced that surgery was indicated for her economic survival. This hernia was interfering with her lifestyle, a lifestyle that relied on constant Valsalva maneuvers, regular pressure on the levators and tourney, and one other specific physical action that editorial propriety prevents me from describing in detail. The hernia was repaired. She resumed her career. This included an adult film award nomination for best performance for the physical activity that editorial propriety prevented me from mentioning in the previous paragraph. The prime negotiating point, therefore, will be that if the hernia is not interfering with the patient's lifestyle, it need not necessarily be repaired. No symptoms after detailed questioning, no repair.

There is, however, one negotiable situation in which an asymptomatic hernia should be repaired. Does the patient plan on spending an extended period of time in a medically underserved area? There are only two areas of the globe that are currently medically underserved. A. A defense installation on an ice floe in the Arctic region. b. A B- or C-list table at a trendy New York, Chicago or Los Angeles restaurant.

The medically underserved aspect of this restaurant seating is key since the patient will die of malnutrition before a wait person appears. The patient will die of starvation prior to incarceration. Which brings us to the third point of negotiation. This is the mediation between the warring incarceration factions. This critical issue has impeded the inception of the Pax Inguinalis. I refer participants to the report of the incarceration subcommittee. What is the statistical chance of a reducible asymptomatic hernia becoming incarcerated?

It is low. What is the statistical chance of an incarcerated hernia becoming incarcerated within 50 yards of an unemployed general surgeon? It is high. So that problem has been solved. As negotiator-in-chief, I anticipate that the pro-repair faction will argue.

1. The hernia will never go away. Of course, it is likely with an aging population that the patient will go away before the hernia goes away. 2. The hernia may enlarge. 3. If the hernia enlarges then the surgery will be more difficult to perform. This argument seems to presume some predetermined hernia doubling time. So, let's repair it now. If the hernia is asymptomatic and is not interfering with the patient's lifestyle the wait-and-see faction will prevail.

If the patient is not headed to a medically underserved area, then I will argue to the assembly to inform the patient about the nature of hernias and to re-evaluate the patient in four to six months. If symptoms appear, then the patient will appear. The surgeon will then have a firm and logical ground on which to stand as the risks and complications of the procedure are outlined. We now address a third critical issue that will confront the participants at the Pax Inguinalis negotiations. This is the issue of the management of posthernia repair pain syndromes. Let us assume that the symptomatic hernia is capably repaired after proper preoperative evaluation.

Both warring camps must understand that the following issues are not negotiable. 1. A hernia repair is not a simple procedure. Many patients are told that hernia repair is a simple procedure. They are told that hernia repair is not a major operation.

Verily, a procedure that is so easy, even a caveman could do it. 2. Thin active patients have more post-operative pain than older sedentary patients. There is a difference between the sexually and athletically active 28-year-old and the sexually and athletically active 80-year-old. Even active males take an average of four to six weeks to recover from a hernia repair.

And by recover, I mean to wake up in the morning and forget that one had a hernia repair. 3. Most post-hernia repair pain will improve and dissipate by watching, waiting, reassuring, exercising, stretching, and the judicious application of brownie and water treatments – showers. 4. If the patient still has pain six months after repair, one should increase the frequency of stretching exercises.

The most valuable type of stretching exercise is the Errol Flynn foil thrust. 5. In most cases, nothing should be done to these patients for at least one year. Most patients will get better with proper instruction and focused, judiciously applied scrotal support.

6. Because most post-operative hernia pain resolves, the workup and investigation of post-hernia pain requires a modicum of diagnostic restraint. In many cases, the impatient patient becomes ensnared in a maelstrom of fruitless diagnostic studies. These diagnostic studies may lead to a series of procedures that may worsen the situation. The surgeon must be steadfast in her knowledge that most posthernia pain will improve. The surgeon must be patient, not impatient like the impatient patient.

Having agreed to these points, the conclave will then consider the pressing issue of the workup and evaluation of posthernia repair pain. I will caution all representatives that once investigative studies of the inguinal region commence, the die has been cast and the Rubicon has been crossed. The Pax Inguinalis is in jeopardy. In the past, it is at this point that regional peace negotiations have broken off. The conclave must consider the following questions.

Can any imaging physician, the artist formerly known as the radiologist, tell you, hey, number 329 is pressing on the neural sheath of the ilioinguinal nerve? Can she tell you that the perineurium is specifically impinged by one of the pseudopods of macrophage number 7899, subsection alpha? Can the nodes of Ranvier be sufficiently detected on an MRI to prove to the surgeon that freeing these nodes will free the patient of pain? At this juncture, the discussion will entertain the metaphysical question, is a numb inguinal region better than a painful inguinal region?

This perplexing question has occupied a great deal of time of some of the greatest surgeons of our age. I can only summarize a hundred years of analysis by repeating what my mentor Dr. Morton R. Feiglbaum of Natick, Massachusetts said about inguinal exploration one snowy afternoon on Harrison Avenue in Boston. Wer weiss? As the mediator intent on instituting the Pax Inguinalis, I bring experience in inguinal re-exploration to the table. I have seen a penis that resembles a stack of four Necco wafers. I have read the chief complaint. My penis disappeared. I have examined a flaccid insensate organ, a shadow of its former self, hanging lifelessly over a once proud testicle. A testicle that now resembles a garbanzo bean at the endless salad buffet at an off-the-strip Las Vegas casino. How do these inguinal unfortunates wind up in this predicament? The tortuous path to inguinodynia will be analyzed at the conference.

Historically, the patient will seek or will be referred for a second surgical opinion. The second opinion may be staffed by the eager minions of a newly incorporated center of excellence. The patient may be logged in as nerve entrapment. This login, such an innocent clerical act, is usually done before the patient is seen and evaluated. It is often recorded before the second opinion has either reviewed the operative report or has demonstrated the rapidly disappearing collegial courtesy of speaking with the original surgeon. Once the nerve entrapment gambit is in play, the course is predictable. If the patient is lucky, the consultant surgeon will be armed with the negotiating points of the Pax Inguinalis. The patient may be referred to a pain center for evaluation.

Pain evaluation centers are a great adjunct to the treatment of post hernia repair pain. There are few marvels of nature more impressive than gazing at a groin full of electrodes hooked up to a dynamometer. 18 months after hernia repair, the patient is now at a crossroads. One road leads to exercise and pain management. The other leads to the recommendation for groin exploration.

The usual argument for groin exploration is a suspicion of a trapped nerve, a nerve encased in a scar that can be specifically identified and then lysed. There are marvelous line drawings of these encased nerves. But if life were like a line drawing then, I would look like Tom Selleck instead of Arnold Stang. What is found at these re-explorations? The surgeon is confronted with scar and distorted anatomy, a cicatricial, concretized, impenetrable ball of fibroblastic misery. All parties at the negotiating table must keep in mind that synthetic mesh is designed to promote scar. It is designed to scar the area because it is designed to fortify tissue and thus prevent recurrent hernias. Mesh grows like a free-spirited blastomere facing inguinal adolescence. After that awkward adolescence, it becomes a mature ball. It experiences a fibroblastic bar mitzvah during which a young and timid entity becomes a mature meshoma. The operative reports of many of these explorations border on opera buffa.

Often the result of the procedure is a denudation of the spermatic cord leading to testicular swelling and pain. Inguinodynia now has a new playmate, orchalgia. A full-fledged inguinal mythology has been created. Dr. Flieberman insulted the inguinal god Inguinodynia. In a fit of rage, Inguinodynia's wife Orchalgia made all of Dr. Flieberman's patients walk funny. Instead of constantly pushing a Sisyphean boulder, the patient must now carry those boulders between his legs. The herniologist has exchanged a transient pain pattern that would have resolved on its own for a real disability. Resolution of this issue moves the conclave to the final phase of negotiations for the Pax inguinalis, consideration of the triple neurectomy, the Supreme Court of Post-Hernia repair pain syndromes. We have had the MRI whose report is akin to, It was a dark and stormy night as our ship approached the pubic tubercle.

We have had the pain consult with injections whose report is laced with confabulatory metacomenta. We have had the groin re-exploration the report of which emulates Professor Irwin Corey on his best Ed Sullivan appearance. We've interrupted the blood supply to the testicle reducing the hopes and aspirations of mankind to a desiccated beer nut. Yet the pain persists. This leads the negotiating group to the triple neurectomy. How is it possible to discuss this operation without conjuring up the Rodney Dangerfield triple Lindy dive in the film Back to School? But I digress, because I am a man of science and I can actually look at Pamela Lee Anderson and think about her dancing ability. The triple neurectomy, the final stop along the Via Dolorosa of posthernia repair pain, which brings the conclave of the Pax Inguinalis to its final agenda item, the research and writings of Dr. Parviz Amid.

Parviz Amid, M.D., has performed over 500 triple neurectomies, excision of the ilioinguinal, iliohypogastric, and the inguinal segment of the genital branch of the genitofemoral nerves. Dr. Amid is the Chief Justice of the Supreme Court of Inguinodynia. This is not on his professional business card. When Dr. Amid reviews his cases he will use the previously described pathways as a vehicle for avoiding posthernia repair pain in the future.

All delegates will be provided with a summary of his experiences and research. The path to the Pax Inguinalis will be smoothed by a cautious review of his valuable work. Dr. Amid's work will foster a unanimity of purpose among the delegates as the negotiations conclude. Protocol is in place. The departmental travel requisitions have been submitted.

Coverage has been arranged. The telephones have been forwarded. The Great Hall at the Pala de Schmerz has been reserved. Surgeons of the world, let us embark on the Pax Inguinalis. Let us establish and maintain a just and lasting peace in the inguinal region.

Respectfully submitted to the participants in the conclave for the establishment of the Pax Inguinalis.