Researchers are taking a look at whether surgery or simply "watchful waiting" is the best option for some men with hernias in their groin or lower abdomen.
Up until now, doctors generally considered the existence of a hernia to be proof that a repair was needed.
"For such a common procedure, it may be surprising to the public that we're asking such a basic question," said Mark Kestner, chairman of the division of general surgery at Lovelace Health Systems. "In medicine, things sometimes evolve, not based on science, but on what we feel is the best thing to do."
About 15 out of 1,000 people develop an inguinal hernia, and about 700,000 operations are performed each year to correct it, he said. The $28 billion cost of those operations amounts to 3 percent of this country's health care expenditures, he said.
A study funded by the National Institutes of Health will find out whether all those operations really are needed. Kestner is heading Lovelace's participation in the study; other study centers are in Nebraska, Texas, California and Wisconsin.
Lovelace hopes to recruit 60 to 80 patients a year, Kestner said. Participants must have inguinal hernias -- those in the groin or lower abdomen -- with no or few symptoms. Surgery is definitely called for in cases in which the person's intestines are caught in the hernia, causing a bowel obstruction with symptoms such as pain, nausea and inability to eat, he said.
Many men, though, have the hernia with no symptoms or only a little cramping that is relieved if they shift position or put pressure on their groin, he said.
"They can push it back in and it (the pain) goes away," Kestner said. "I have men who come in, say they had it all their life, and feel that is normal for them."
Such a hernia is more common in men, he said. The testicles, which initially are formed in the abdominal cavity near the kidneys, can leave weak spots or a fingerlike projection in the abdominal wall when they migrate outside the body, Kestner said.
That weak spot in the muscles and tissue of the abdominal wall can let the internal matter sag through. Surgery to correct the weakness was considered a good idea because of problems that can be caused by the intestine getting caught in the hole, he said.
"But we've begun to believe that event is relatively rare," Kestner said, adding that the material pushing through usually is a layer of fat.
Men in the study will be randomly assigned to the surgery or "watchful waiting" approaches. Surgery involves cutting through the skin and abdominal wall to insert a polypropylene patch -- it's like plastic screening you might use to fix a hole on your door or window screen -- into the weak spot in the abdominal wall, Kestner said. The person's own muscle layers and a few stitches hold it in place.
The day surgery can be done with a local or general anesthetic, he said. Post-surgical pain in the groin lasts for two to three weeks.
Kestner said he advises his patients not to go to work for seven to 10 days after the surgery, and not to lift anything heavier than a telephone book for two to three weeks afterward. "That's probably very conservative," he added.
"Watchful waiting" simply means keeping an eye on the hernia and making sure it doesn't get bigger or catch the intestine. Patients will be followed for 21/2 to 5 years, Kestner said.
Lovelace started recruiting study participants at the beginning of February and will continue for the next 21/2 years, he said.
People do not have to be members of the health plan to participate, he said, but the study does not cover the cost of surgery. Those interested in taking part can ask for a referral from their physicians or call 262-7260.
"This is sort of an exciting thing to be involved in," Kestner said. "I think the patients we recruit for it are truly interested in helping us come up with the right answer."
