Men’s Health: To Truss or Not to Truss?

by Linda Grace, BA

With increasing numbers of medical studies suggesting that up to 30% of hernia repair operations can lead to postoperative complications such as chronic pain, numbness, or infections, what is the future for the treatment of inguinal hernias?

Inguinal hernias are one of the most common afflictions of adult men, and hernia repair surgery (herniorrhaphy) is one of the most common surgical operations. In the US, 2800 herniorrhaphies per 1 million population are performed per year, and 1000 per million in the UK. This surgery has been viewed as necessary to prevent life-threatening complications such as bowel obstruction or strangulation. The Society of Surgery for the Alimentary Tract (SSAT) in the US recommends that patients with groin hernia should undergo surgical evaluation within a few weeks after detection.¹ This is due to a common belief that progression of a hernia is inevitable and that the operation becomes more difficult the longer the hernia is left unrepaired.

But in 2006, a study by Fitzgibbons et al. started a hot debate in the medical community. For 2 to 4.5 years, Fitzgibbons and his team followed up 720 men from five North American centers, who were assigned either to observation (“watchful waiting”) or to herniorrhaphy. Pain and discomfort interfering with usual activities were compared between the two groups. There was no significant difference between them, and the researchers concluded that if patients should understand that, moderate hernia, they don’t have to have it fixed.²

Other researchers had already been producing ever more startling statistics on the incidence of long-term complications after herniorrhaphy. Bay-Nielsen et al. followed 210 patients in Denmark for six years after surgery, and found that 34% were still suffering persistent pain in the area of their hernias.³ Fränneby et al. in Sweden followed 2456 patients by questionnaire for 2 to 3 years after they underwent hernia surgery. Thirty-one percent reported that they still had some pain; in 6%, the pain interfered with daily activities.⁴ In the Netherlands, Loos and Roumen found that of 1766 men followed for three years, 40.2% were still suffering some degree of pain, and 1.9% experienced severe pain. Almost one-fourth reported numbness that correlated significantly with pain. One-fifth of the patients felt functionally impaired in their work or leisure activities.⁵

Late-onset infection, while much less common, is another potential complication. In Greece, Delikoukos studied 954 men who had received hernia repair surgery using polypropylene mesh. Five patients (0.35%) developed a mesh infection 2 to 4.5 years after the surgery.⁶ Eighty cases of mesh-related infection were reported to the US Food and Drug Administration in 2008.⁷

Nowadays, most herniorrhaphies are carried out using the mesh repair method, which involves inserting a patch of plastic mesh to strengthen the inguinal region. Success depends upon tissues’ growing around and through the mesh, forming scar tissue and creating a firm but tension-free barrier against the hernia’s reemerging. But because of the way mesh incorporates itself into surrounding tissue and organs, its removal can be very difficult or even impossible, since it requires cutting out a section of body tissue. So if chronic pain, numbness, late-onset infection, or hernia recurrence of the s, there may be no simple remedy. While some studies report rates of hernia recurrence of 5% to 10% after mesh repair,¹⁴ others have reported rates of up to 16%.^8,9 When chronic complications occur, it is not uncommon for patients to be told that nothing can be done except to take strong painkillers for life.¹⁰ There is also a growing tendency to offer pain prevention in the form of routine prophylxcision.¹¹

Watchful Waiting

This is a policy that consists of monitoring a patient instead of offering immediate treatment. Although hernias are likely to progress over time to incarceration (that is, the bulge is no longer “reducible” but becomes trapped and cannot be pushed back into the abdomen), this does not seem to be associated with a significant increase in morbidity or even emergency surgery.¹² The concern that a hernia may be more difficult to repair the longer it goes untreated was an issue before mesh repairs became popular, but this concern has now largely been eliminated.¹² Research from the University of Nebraska (USA) has found no significant difference in terms of operative time, surgical complications, recurrence rates, and satisfaction with outcome between patients treated with watchful waiting and those referred for immediate surgery.¹³ O’Dwyer et al. drew similar conclusions after a randomized clinical trial in the UK.¹⁴ However, it should be borne in mind that if a hernia becomes strangulated, the rate of morbidity and mortality associated with an emergency repair is much higher than for an elective repair.

Some surgeons are actively campaigning for patients to be given the full facts, so that they can make an informed decision on whether to go ahead with surgery. Jonathan L. Meakins of the Radcliffe Infirmary (UK) reports that a surprising number of his patients terminate the consultation immediately on hearing of the potential consequences of an operation. “Why would someone with an asymptomatic inguinal hernia trade that state for a chance to have chronic pain, hypoesthesia or any degree of sexual dysfunction? Surely this is a clinical situation for which joint decision-making is appropriate. The patient decides but the surgeon offers, rather than recommends an operation.”¹⁵

Several Regional Health Authorities in the UK have had recent policy reviews and have reclassified the elective surgical treatment of asymptomatic or mildly symptomatic inguinal hernias in adults as a low-priority treatment.¹⁶

To Truss or Not to Truss?

The hernia belt, or truss – whose purpose is to keep a reducible hernia “in” – used to be the only treatment for an inguinal hernia before surgery became the norm. Early versions of the truss were ill-fitting contraptions made from leather and canvas with metal springs. The 19th century Eggleston’s Truss from Chicago was described as follows:

Eggleston’s Truss has a pad different from all others. It is cup-shaped, with a self-adjusting ball in the centre, and adapts itself to all positions of the body, while the ball in the cup presses back the intestines just as a person does with the finger. With light pressure the hernia is held securely day and night, and a radical cure is certain. It is easy, durable and cheap.¹⁷

Later developments resulted in the Cluthe truss, described in Cluthe’s Advice to the Ruptured, published in 1912. This book includes dozens of testimonials from patients who claimed to be cured by this relatively primitive device. These cases are clearly not scientific evidence, but we have little other data on the use of trusses.¹⁸

A famous German clinic, the Bilz Sanatorium, produced a book in 1898 that detailed its treatments. It considered that hernia cures were commonplace, and recommended simple exercises, mineral baths, and the conscientious wearing of a truss or support until the hernia was cured. Of course, many hernias probably continued to cause problems, but the use of a rupture truss was seen as a step toward the restoration of full good health.¹⁹

Nowadays, most doctors and surgeons do not prescribe trusses, and the SSAT positively discourages them: “Hernia belts or trusses should be discouraged, and should be limited to patients who are not candidates for an elective operation. Chronic scarring from their use can lead to a more difficult repair and higher risks of complications.”¹ Even some of today’s trusses use metal springs to apply pressure to the hernia, via a pad that can be quite hard and usually bulges into the hernia. It is this protrusion that promotes the formation of scar tissue around the edges of the hernia, and so prevents them from knitting together and healing.

Most trusses must be initially fitted by an experienced fitter. Careful measurements must be taken before the fitting, with the patient undressed and standing up. Then the hernia must be reduced by getting the patient to lie down and if necessary gently applying pressure with a finger. Even so, all these measures may not be enough. According to one surgeon: ‘It’s nearly impossible to get a truss to fit in such a way as to keep the hernia in at all times. So don’t bother.”²⁰

Clearly, in order to best achieve its purpose, an inguinal hernia support needs to fit well, be comfortable, keep the hernia in at all times, and be free of springs or pads that bulge inwards. The Support Company in the UK believes that it has achieved this. Testing of its Flat Pad Support by individuals from karate students to Ironman athletes has produced many reports that the hernia stays in, even during sports and heavy manual labor.²¹ Clinical trials have not yet been conducted, but only about 3% of garments are returned as uncomfortable or ineffective. This support consists of a firm elastic belt with rigid flat pads designed to slide together in such a way that they remain permanently in contact with the hernia area.

While it remains to be clinically proven that keeping a hernia in can prevent it from progressing, many users of the Flat Pad Support report improvements in their quality of life, such as greater comfort, and confidence to carry out physically demanding tasks and abdominal exercises.²²

Can a Hernia Heal Itself?

The Support Company’s sister website, www.herniabible.com, is collecting case reports from individuals who claim to have healed their own hernias. These can be viewed at http://www.groin-hernia.com/phpBB/viewtopic.php?t=274. The most compelling of these cases is described in more detail at http://ehealthforum.com/health/topic43624_20.html. After feeling convinced that he was cured, the patient (“Anthonee”) asked his doctor to confirm it with an ultrasound examination.

The factor that most of these individuals have in common is the use of exercises such as yoga and Pilates to develop core strength. Other self-treatments include the wearing of a support, and the use of homeopathy, herbs, and nutritional supplements.

Notes

1. SSAT patient care guidelines: surgical repair of groin hernias [web page]. Society of Surgery for the Alimentary Tract (SSAT). http://www.ssat.com/cgi-bin/hernia6.cgi.

2. Fitzgibbons RJ Jr, Giobbie-Hurder A, et al. Watchful waiting vs. repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006 Jan 18;295(3):285–292.

3. Aasvang EK, Bay-Nielsen M, Kehlet H. Pain and functional impairment 6 years after inguinal herniorrhaphy. Hernia. 2006 Aug;10(4):316–321.

4. Fränneby U, Sandblom G, Nordin P, Nyrén O, Gunnarsson U. Risk factors for long-term pain after hernia surgery. Ann Surg. 2006 Aug;244(2):212–219.

5. Loos MJA, Roumen RMH. Chronic sequelae of common elective groin hernia repair. Hernia. 2007;11:169–173.

6. Delikoukos S, Tzovaras G, Liakou P, et al. Late-onset deep mesh infection after inguinal hernia repair. Hernia. 2007 Feb;11(1):15–17.

7. MAUDE – Manufacturer and User Facility Device Experience [website]. US Food and Drug Administration. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/TextSearch.cfm.

8. Neumayer L, Giobbie-Hurder A, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004 Apr 29;350(18):1819–1827.

9. Aasvang EK, Bay-Nielsen M, Kehlet H. Pain and functional impairment 6 years after inguinal herniorrhaphy. Hernia. 2006 Aug;10(4):316–321.

10. Hernia surgery am I unlucky? In: Hernia bible forum for groin pain and inguinal hernia [Internet]. http://www.groin-hernia.com/phpBB/viewtopic.php?t=286. Oct. 2, 2008.

11. Dittrick GW, Ridl K, Kuhn JA, McCarty TM. Routine ilioinguinal nerve excision in inguinal hernia repairs. Am J Surg. 2004 Dec;188(6):736–740.

12. Turaga K, Fitzgibbons RJ Jr, Puri V. Inguinal hernias: should we repair? Surg Clin North Am. 2008 Feb;88(1):127–138.

13. Thompson JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg. 2008 Jan;195(1):89–93.

14. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg. 2006 Aug;244(2):167–173.

15. Meakins JL. Watchful waiting for asymptomatic inguinal hernia [letter]. BMJ. 21 February 2008. Available at: http://www.bmj.com/cgi/eletters/336/7638/269#190862.

16. Hernia Bible. Articles comparing surgery with watchful waiting [web page].http://www.groin-hernia.com/herniabible/articles.html.

17. Scientific American. March 1879;40(13).

18. Cluthe C. Cluthe’s Advice to the Ruptured. Cluthe Truss Establishment: New Jersey; 1912. Available at: http://www.groin-hernia.com/herniabible/downloads/CluthesAdvice.pdf.

19. Bilz FE. The Natural Method of Healing: A New and Complete Guide to Health. Dresden: Bilz Sanatorium; 1898.

20. Schwab S. Awaiting the rupture. Oct. 15, 2006. In: Surgeonsblog. http://surgeonsblog.blogspot.com/2006/10/awaiting-rupture.html.

21. Hernia Bible. Roy’s story: Iron man and triathlon athlete [web page]. http://www.herniabible.com/roy.html.

22. Support Company. The Flat Pad support: testimonials [web page]. http://www.groin-hernia.com/testimonials.html.

Linda Grace, BA

The Support Company

32 Wellington Square

Hastings, East Sussex TN34 1PN

United Kingdom

www.thesupportcompany-uk.com

www.herniabible.com

Linda Grace is a cofounder of The Support Company and www.herniabible.com. The Support Company supplies the Flat Pad Support to doctors and patients worldwide. It welcomes inquiries from researchers who are interested in assessing this product’s impact on quality of life during watchful waiting programs.