My doctor advised me to have my hernia treated even though it doesn’t hurt me. I would like to have the procedure under local anesthesia, but the surgeon said the only options on the NHS were general or spinal – is that right?
James Anthony, Hertford, Herts.
Hernias are very common and occur when part of an organ is moved and pushes through the structures that contain it, creating a bulge through the skin.
In men, the most common type is an inguinal hernia, in which fatty tissue or part of the intestine punctures the groin on one side, usually at the top of the inner thigh.
In women, we often see paraumbilical hernias – or ‘umbilical hernias’ – that occur just above the navel and usually result from a natural weakening of the abdominal wall after the muscles of the abdomen have been stretched during pregnancy. Also common are incisional hernias, at a site from previous surgery.
Most hernias cause few symptoms. However, over time they tend to enlarge and in rare cases can suffocate, which means that a tissue loop within the hernia rotates and becomes trapped, cutting off its own blood supply.
In women, we often see paraumbilical hernias – or ‘umbilical hernias’ – that occur just above the navel and usually result from a natural weakening of the abdominal wall after the abdominal muscles have been stretched during pregnancy. [File photo]
Immediate surgery is then essential to ensure that the stuck part of the tissue (in the bowel, for example) does not die and become gangrene – a situation that can be life-threatening.
The risk of strangulation is why preventive surgery is often recommended, even for hernias that do not seem to cause pain or concern to a patient.
I am sympathetic to your request to have the surgery performed under local anesthesia – a major advantage is that you can leave the hospital immediately, and the results are just as good as those under general anesthesia.
However, the recommended keyhole surgery cannot be performed in this way.
The risk of strangulation is why preventive surgery is often recommended, even for hernias that do not appear to cause a patient pain or concern [File photo]
To create the laparoscopic cavity – the room for the camera and other instruments needed to ‘repair’ the hernia – the abdominal cavity must be pumped full of gas.
This allows the bowels to be moved out of the way and allows access to the opening that the hernia pushes through. The procedure also requires paralysis of the abdominal muscles – which is only possible with general anesthesia.
To have the surgery under local anesthetic, you will need open surgery, which will require a 10 cm incision (assuming you have an inguinal hernia from your longer letter).
This can be done, and it is unclear why the surgeon advised you that your only options were general or spinal anesthesia. There is no universal dictation and it is likely that another NHS surgeon would perform the open surgery option for you under local anesthesia.
My husband is 75 and has had high blood pressure for most of his life. The most recent addition to his medication regimen, 5mg amlodipine, has left him with very swollen legs. Taking water tablets did not help.
Name and address provided.
The medications your husband is taking to treat his high blood pressure (or hypertension) are essential to protect him from stroke and heart damage.
Three of the medications he’s taking – doxazosin, minoxidil, and amlodipine – are known to cause fluid retention (or edema). Gravity causes the excess fluid to float down, making it look like leg swelling.
In your longer letter, you say that your husband’s doctor ruled out other causes, including heart failure, by giving him the blood test for B-type natriuretic peptide (BNP).
This hormone is released from heart cells when the organ is stretched or the muscle is weakened. (I should add that an ultrasound – an echocardiogram – is the gold standard for detecting heart failure. Some patients will have heart failure but normal BNP levels, while others may have elevated BNP levels and near-normal heart function.)
But why haven’t the diuretics helped with water retention?
I wonder if there is another contributing factor – varicose veins or sedentary lifestyle, for example. Walking improves the flow of lymph (tissue fluid) back to the heart and into the circulation.
Compression stockings, which apply pressure and reduce tissue fluid, can be prescribed. I would suggest your husband put these on first every morning and go for a walk – a mile would be the goal.
This will limit the swelling and also benefit his hypertension.
The medications your husband is taking to treat his high blood pressure (or hypertension) are essential to protect him from stroke and heart damage [File photo]
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In my opinion: GPs should ask questions about lifestyle and nutrition
‘Let food be your medicine and medicine be your food’ – the words, it is thought, of Hippocrates of Kos, the ancient Greek physician known as the father of medicine (he also wrote the Hippocratic Oath, the ethical doctor’s code).
Diet and lifestyle were key themes in Hippocrates’ writings, and he insisted that both were central to a physician’s work.
Yet despite the fact that unhealthy eating is a leading cause of heart disease, type 2 diabetes, and other conditions related to premature death, few of us are routinely asked about what we eat by our doctors.
The only resource I know of for this is the dietitian’s food diary – a detailed record that you keep for a week, detailing how much and what kind of food and drink you eat.
However, dietitians appear to be an underused resource.
Regardless, it is surprising that doctors have so little interest in what their patients eat. It doesn’t help that the Quality Outcomes Frame work, which rewards GPs for providing certain services (such as vaccinations), does not encourage them to focus on a healthy diet.
Now the American Heart Association proposes that routine consultations should always focus on nutritional assessment (the best tools for this are being evaluated).
There’s no reason the same shouldn’t happen here in the NHS. We need a professional dietitian in every general practice, or evidence-based reliable resources for general practitioners and practice nurses to help prevent and treat the myriad of nutritional and lifestyle related conditions.
Part of the reason for this huge gap in the medical world is a lack of knowledge about the vast array of molecules in food and how they affect health (for example, we are still learning how much the bacteria in our gut absorb and modify the food molecules that we have eaten).
But we can’t wait to find out all about it – rising obesity levels and the huge associated costs to the NHS mean we need to get the ball rolling now.