My doctor has advised me to have my hernia treated, even though it doesn’t cause me pain. I would like to have the procedure under local anaesthetic, but the surgeon said the only options on the NHS were general or spinal — is that so?
James Anthony, Hertford, Herts.
Hernias are very common and occur when part of an organ becomes displaced and pushes through the structures that contain it, creating a bulge through the skin.
In men, the most common type is an inguinal hernia, where fatty tissue or a part of the intestine pokes through into the groin on one side, usually at the top of the inner thigh.
In women, we often see paraumbilical hernias — or ‘belly button hernias’ — which occur just above the navel and are usually due to a natural weakening of the abdominal wall after the muscles of the abdomen have been stretched in pregnancy. Also common are incisional hernias, at a site of previous surgery.
Most hernias cause few symptoms. However, over time they tend to enlarge, and in rare cases can strangulate, which is when a loop of tissue within the hernia rotates and becomes trapped, cutting off its own blood supply.
In women, we often see paraumbilical hernias — or ‘belly button hernias’ — which occur just above the navel and are usually due to a natural weakening of the abdominal wall after the muscles of the abdomen have been stretched in pregnancy [File photo]
An immediate operation is then essential to ensure the trapped section of tissue (for example, in the bowel) does not die and become gangrenous — a situation that could be life-threatening.
The risk of strangulation is why preventative surgery is often recommended, even for hernias that appear to cause a patient no pain or concern.
I am sympathetic to your request to have the operation under local anaesthetic — one major advantage is that you can leave hospital immediately, and the results are just as good as those achieved under general anaesthetic.
However, the keyhole surgery that has been recommended cannot be carried out this way.
The risk of strangulation is why preventative surgery is often recommended, even for hernias that appear to cause a patient no pain or concern [File photo]
In order to create the laparoscopic cavity — the space for the camera and other instruments needed to ‘fix’ the hernia — the abdominal cavity must be pumped full of gas.
This allows the intestines to be moved out of the way, giving access to the opening through which the hernia is pushing. The procedure also requires paralysis of the abdominal muscles —which is only feasible with a general anaesthetic.
To have the operation under a local anaesthetic, you’d need open surgery, requiring a 10cm incision (assuming from your longer letter that you have an inguinal hernia).
This can be done, and it is unclear why the surgeon advised that your only options were general or a spinal anaesthesia. There is no universal diktat, and it is likely that another surgeon on the NHS would perform the open surgery option for you under a local anaesthetic.
My husband is 75 and has had high blood pressure for most of his life. The most recent addition to his drug regimen, 5mg amlodipine, has given him very swollen legs. Taking water tablets has not helped.
Name and address supplied.
The drugs 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 drugs he takes — doxazosin, minoxidil and amlodipine — are known to cause fluid retention (or oedema). Gravity causes the excess fluid to drift downwards, so it appears as swelling of the legs.
In your longer letter you say that your husband’s doctor has excluded 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 scan — an echocardiogram — is the gold standard for detecting heart failure. Some patients will have heart failure but normal BNP levels, while others can have raised BNP levels and almost normal heart function.)
But why haven’t the diuretics helped with the water retention?
I wonder whether there is another contributing factor — varicose veins, for example, or a sedentary lifestyle. 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 puts these on first thing each morning and takes a walk — a mile would be the aim.
This will limit the swelling and be of benefit for his hypertension, too.
The drugs 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 view: GPs must ask about lifestyle and diet
‘Let food be thy medicine and let medicine be thy food’ — the words, it’s thought, of Hippocrates of Kos, the Ancient Greek physician known as the father of medicine (he also wrote the Hippocratic Oath, the doctors’ code of ethics).
Diet and lifestyle were key themes in Hippocrates’ writings, and he insisted both were central to a doctor’s work.
But despite the fact that unhealthy eating is a major cause of heart disease, type 2 diabetes and other conditions linked to early death, few of us are routinely asked by our doctors about what we eat.
The only tool I know for this is the dietitian’s food diary — a detailed record you keep for a week, setting out how much and what kind of food and drink you consume.
Dietitians, however, appear to be an under-utilised resource.
Regardless, it’s surprising doctors take 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 incentivise them to focus on healthy diets.
Now the American Heart Association is proposing that routine consultations should always aim to include dietary assessment (the best tools for this are being evaluated).
There’s no reason why the same should not occur here in the NHS. We need a professional dietitian in every GP surgery, or evidence-based reliable tools for GPs and practice nurses to help prevent and treat the myriad conditions linked to diet and lifestyle.
Part of the reason for this vast hole in the world of medicine is a lack of knowledge about the huge array of molecules in food and how they affect health (we’re still learning, for instance, just how much the bacteria in our intestines absorb and modify the food molecules we’ve eaten).
But we can’t wait until we know everything — rising obesity levels and the enormous associated cost to the NHS mean we need to get the ball rolling now.