Does my wife need to have a hernia repair?

MY WIFE, nearly 72, has been diagnosed with a para-umbilical hernia. Sometimes there is a lump the size of a large egg. Is it advisable to have a surgical repair?

What are the possibilities of serious problems if it is not repaired?

P. L. Upson, Braintree, Essex.

HeRniaS, where an organ protrudes through its coverings, are common, affecting around a quarter of men and 3 per cent of women at some point.

Most commonly, it is a loop of intestine that pushes through a weakness that has opened up in the muscles of the abdomen or groin when the person is standing or straining.

in the case of a para-umbilical hernia, the weakness or defect is usually in the middle of the abdomen, a short distance above the belly button.

The bowel pushes through a gap between two straps of muscle called the rectus abdominis muscles, which stretch from the rib cage to the pelvis.

This type of hernia can occur in babies, but also in adults as a result of the muscles becoming weakened — for example, because of age, weight gain, anything that increases pressure in the abdomen, such as pregnancy, a persistent cough, constipation, heavy lifting or just general unfitness.

Though a hernia is usually not painful, it should always be investigated by a gP.

This involves palpating the area carefully with the fingertips when the muscles are relaxed to determine the size of the gap between the muscles.

if the gap is not too small and tight, the contents of the hernia will flop back when the person is lying down.

in cases where it is tight, the contents may not slip back and in these circumstances a loop of intestine may be stuck, a condition called incarceration.

ThiScan lead to a blockage of the bowel — with pain and vomiting — known as obstruction, or even strangulation, when the loop rotates and cuts off its own blood supply, leading to gangrene of the bowel (where the tissue dies).

either of these eventualities is a surgical emergency, and for that reason, though it is not essential to repair a painless para-umbilical hernia that does reduce back into the abdomen, it is advisable to operate.

Better to resolve a relatively minor problem than be forced to carry out an emergency procedure, maybe out of routine hours, if a complication such as obstruction or strangulation should occur. Such surgery is major and more dangerous. Repair of an uncomplicated para- umbilical hernia is straightforward: in many patients, this can be carried out under a local anaesthetic.

Typically, the surgeon makes a small incision near the belly button, then pushes the loop of bowel back into the abdomen, stitching together the weakened muscle layers.

Sometimes a mesh is used to strengthen the area as an alternative to stitching the muscles or as an additional measure.

Whether under local or general anaesthetic, the operation should not involve more than one night in hospital.

My advice would be to proceed if you are given this option. MY HUSBAND was diagnosed with trigeminal neuralgia in 2010 and has recurring bouts every two years. Each time it seems to be getting worse.

At present, he is taking pregabalin and Tegretol. He has heart problems, having had a triple bypass in 2003 and then another heart attack in 2009, so is resistant to some medicines. Could you offer some advice?

Mary McWilliam, by email. TRigeMinal neuralgia is a disorder of the trigeminal nerve, which runs from the brain to the face. The condition is characterised by sudden severe electric shock-like pains, typically on one side of the face.

These pains are usually triggered by simple stimuli, such as touching the face, talking, cleaning the teeth or even just smiling.

The old-fashioned term for this rare condition was tic douloureux, reflecting the facial muscle spasms that may occur during the intense bouts of pain.

The cause in most cases is irritation or compression of a small section of the trigeminal nerve by a blood vessel that is running an abnormal course.

The errant vessel will always have been present, but why it should suddenly start stirring up this trouble later in life (most cases are diagnosed after the age of 50) is uncertain.

The pressure on the nerve reduces the myelin sheath, the insulating covering on the nerve; this can interfere with the way the nerve functions.

again, why the pain occurs in bouts is not yet understood.

Medication is the main treatment option, and it is only when this fails that surgery is contemplated.

Your husband is taking the best-known drug, carbamazepine (its trade name is Tegretol).

evidence from four wellconducted studies shows that this drug provides pain relief in 60 per cent to 100 per cent of patients, though side-effects can be a problem.

These can be minimised by starting at the low dose of 100mg twice daily and working up very slowly, over weeks and months, to a total daily dose of between 800mg and 1,200mg.

i suspect that, on its own, this drug was not suppressing your husband’s bouts of pain effectively, and so his doctor has prescribed an add- on drug, pregabalin.

There are other options, mainly anticonvulsants: drugs that are used to calm irritable malfunctioning nerves at various sites.

it may well be that at least some of these have been tried on your husband — though, of course, it is possible to do so only when he is going through one of the bouts.

Whenmedical treatment fails, surgery may be used to relieve trigeminal neuralgia. Microvascular decompression is a major operation; it is invasive, requiring surgery into the skull to remove or relocate the offending blood vessel.

it brings relief in 90 per cent of patients, but at the risk of complications.

less invasive is a treatment called gamma knife, a form of radiotherapy. it provides pain relief a few weeks after the procedure, but this success drops to about 70 per cent of patients after one year and 50 per cent at three years.

My advice is that your husband must continue under the regular care of a neurologist or a neurosurgeon who has a special interest in this condition.

This is essential given his history of coronary heart disease and the need to ensure that any medicines added on a trial basis are not in conflict with any of the medication needed for his heart.

On balance, it may well be that if all medications have failed, the gamma knife treatment — if available where you live — would be a good and safe option.

WRITE TO DR SCURR

TO CONTACT Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk — including contact details. Dr Scurr cannot enter into personal correspondence. His replies cannot apply to individual cases and should be taken in a general context. Always consult your own GP with any health worries.