Sunday, January 23, 2011

The Gorman No-Mesh Gold Standard for Hernia Surgery

The Gorman No-Mesh Gold Standard for Hernia Surgery
1.0        Introduction  

2.0        DEFINITIONS

2.01      What is The Abdominal Wall?
2.02      What is A Hernia?
2.021    Natural Causes of Hernias
2.022    Man-Made Causes of Hernias

3.01      Background
3.02      The New Gold Standard for Hernia Surgery
3.03      Defining The Gold Standard
3.04      The Statistical Results
3.041    Complications Avoided by The Gorman Technique
3.0411  Mesh Foreign Body Complications
3.0412  Other Complications Minimized by The Gorman Technique
3.042    Statistics Showing The High Rate of Cure
             3.0421       Definition of  "Permanent Cure"                                                                     3.0422     The High Quality of the Statistics                                                                       3.0423       The Statistics Themselves                                                                                                                    
                 3.04231        Inguinal Hernia Statistics
                 3.04232        Umbilical Hernia Statistics
                 3.04233        Incisional Hernia Statistics
                 3.04234        Recurrent Inguinal Hernia Statistics
3.042341           Special Points About The Gorman Technique for Recurrent Inguinal Hernias
3.0423411         Recurrences After Original Laparoscopic Operations
3.0423412         Treating the Rare Recurrence After Original Gorman Technique

4.01      Incarceration of Hernias
4.011    Incarceration Later in Life
4.012    Diet and Incarceration
4.013    The “Quiet Hernia” – Unrecognized Incarceration?

5.0        WHAT IS THE ACTUAL SURGICAL TECHNIQUE?                                                                                                                                                                                                                       
6.01      The Four Stages of Any Operation
6.011    The Four Stages in “The Gorman Gold Standard Experience”
6.0111  Inguinal Hernias
            6.01111    One-Sided Inguinal Hernias – The Four Stages
6.01111-1          Stage (1) The First 18 Hours
6.01111-2          Stage (2) The Full Recovery Period
6.01111-3          Stage (3) Complications (or Lack Thereof)
6.01111-4          Stage (4) Attaining Permanent Cure

                        6.01112    Two-Sided (“Double”) Inguinal Hernia – The Four Stages
6.01112-1          Stage (1) The First 18 Hours
6.01112-2          Stage (2)  The Full Recovery Period
6.01112-3          Stage (3)  Complications (Or Lack Thereof)
6.01112-4          Stage (4)  Attaining Permanent Cure                             
 6.0112   Umbilical Hernias – The Four Stages
6.0112-1           Stage (1) The First 18 Hours
6.0112-2           Stage (2)  The Full Recovery Period
6.0112-3           Stage (3)  Complications (Or Lack Thereof)
6.0112-4           Stage (4)  Attaining Permanent Cure
6.0113 Incisional Hernias – The Four Stages
6.0113-1           Stage (1) The First 18 Hours
6.0113-2           Stage (2)  The Full Recovery Period
6.0113-3           Stage (3)  Complications (Or Lack Thereof)
6.0113-4           Stage (4)  Attaining Permanent Cure

7.0        Appendices
The Gorman No-Mesh Gold Standard is a New Technique for treating Hernias of the abdominal wall. It is more than a concept; it is actually a comprehensive surgical technique developed by Dr. Joel Gorman that has proven itself abundantly in over 20 years and thousands of operations. The Technique repairs all kinds of hernias (umbilical, inguinal, incisional) by a special reinforcing weave of the abdominal muscles. It provides an excellent alternative for mesh repairs, giving superior results with none of the complications of mesh foreign body. The Gorman No-Mesh Technique lends itself to the repair of the simplest as well as most complicated hernias, usually with only local anesthesia and a short hospitalization. Furthermore, all these advantages extend to overweight individuals, and women who will want future pregnancies as well.
The following article will describe in more detail this New Gold Standard for Hernia Surgery.
Making the best decision about treating your hernia requires some knowledge about the abdominal wall and hernia disease of it.
What is the abdominal wall?
The abdominal wall is one of the largest organs of the human body. It is what people call the “belly” or “stomach”. Actually it is the muscular layer that surrounds the abdominal cavity in front and on the sides.
When you think about it, the abdominal wall has some important functions. First, it keeps the contents of the abdominal cavity from going anywhere, and at the same time protects them from injury. These contents are the small intestine and colon, the bladder and gynecologic organs, the liver and spleen and other internal organs, as well as much intraabdominal fat. Second, the abdominal wall provides the muscular strength for us to sit or stand up when we are lying on our back, and to bend over and straighten up when we are standing. Indeed, normal daily activity depends on a healthy abdominal wall. Finally, the abdominal wall with its overlying skin and fat gives the esthetic shape to much of our body.
What is a Hernia?
A hernia is a protrusion of some of the abdominal contents out through a hole in the muscles of the abdominal wall. You will want to know about your hernia where the hole is and what is protruding out through it. It is also interesting to know what caused the hole. The options are as following.
Natural Causes of Hernias
The hole can be caused by a naturally weak place in the abdominal wall opening up. This is common at the belly button (“umbilicus”) and the groin (“inguinal region”). When bowel or fat protrudes through the hole at one of these places, the bulge felt under the skin is called an umbilical hernia or inguinal hernia. More technically, the hole in these naturally weak areas can be described as congenital or present at birth, or acquired naturally due to the wear and tear of aging.
Man-made causes of hernias
The hole can also be man-made, caused by a complication of previous surgery. Operations are very common in the abdomen and require cutting through or “incising” the abdominal wall. At the end of the operation, the incision in the muscles is stitched together. (The skin is stitched separately after this). This man-made weak area in the muscles may open up later, so that bowel or fat protrudes out. This is felt as a bulge under the skin, and is called an “incisional hernia”. It is a complication of 10-20% of all abdominal operations, including laparoscopy.
Now that you know what a hernia of the abdominal wall is, it is time for some general information about Dr. Gorman and the Gorman No-Mesh Technique.
Dr. Joel Gorman is an internationally known general surgeon who, after medical school and early training in the U.S., has practiced surgery in Israel for 25 years. He was influenced by the modern originator of the nylon darn no-mesh hernia repair, Dr. Jack Abrahamson. For 20 years Dr. Gorman has specialized in abdominal wall surgery, broadening and perfecting his unique No-Mesh Technique for all types of hernias.
He recently presented the results with his Gold Standard Technique before The American College of Surgeons (Washington D.C.; October, 2010) and The American Hernia Society (San-Francisco, March, 2011) of which he is a member.
The New Gold Standard for Hernia Surgery
The motto motivating Dr. Gorman’s surgery is, “To do the most successful hernia repair, while avoiding the complications of mesh foreign body”. By achieving this, Dr. Gorman has achieved The New Gold Standard for hernia surgery. This will now be explained.
Defining the Gold Standard
First, what exactly is meant by the Gold Standard designation? Any surgical operation which always achieves its goal of curing a specific surgical disease, and does so without itself causing any future complications, might well be called a Gold Standard Operation. The Gorman No-Mesh Technique indeed cures hernia disease, resulting in an abdominal wall that is completely normal. All activities dependent on the abdominal wall, including lifting, athletic sports, and pregnancy, can be carried out normally for the rest of the patient’s life. Meanwhile, absolutely no complications of mesh foreign-body are encountered at any time since no mesh is ever used. Therefore, the Gorman Technique is called The New Gold Standard for Hernia Surgery. Of course, this is backed up by Dr. Gorman’s 20-year experience with well over 1,500 operations of abdominal wall hernias. The statistical results from this experience are important and will now be described.
The statistical results
It will be shown using statistics that the Gorman Technique gives:
1.    no mesh complications (and essentially no other complications), and
2.    the highest level of cure.
Complications Avoided by The Gorman Technique:
Mesh Foreign Body Complications
Regarding mesh complications, the total absence of mesh foreign body complications is 100% assured with the Gorman No-Mesh Technique because, as the name implies, meshes are not used anywhere at any time. This is clear enough.
As to the types of complications occurring with meshes, patients referred to Dr. Gorman have shown the following problems: a feeling of a stiff abdominal wall (“stiff abdominal wall syndrome”); chronic pain (“meshodynia”); chronic infection, and even erosion of the mesh into the bowel or bladder (“fistulization”). Removing the mesh for any of these complications is difficult and dangerous, especially if the mesh was originally inserted by laparoscopy.
Another complication of meshes which Dr. Gorman sees quite often regards future childbearing. Women who ask their surgeon about having children after a mesh operation for their abdominal wall hernia, may be told that becoming pregnant after the mesh operation is unadvisable since during pregnancy the mesh may be painful and possibly increase the chance of abortion, or the mesh may fail with hernia recurrence. Sometimes these women are even advised to undergo sterilization at the time of the mesh operation, in order to avoid later pregnancy.
So, considering the potential severity of mesh complications, their complete absence after the Gorman No-Mesh is ideal.
Other Complications Minimized by The Gorman Technique
Other potential complications of hernia surgery which are avoided by The Gorman Technique will be discussed  briefly. Dr. Gorman uses local anesthesia as much as possible, thus avoiding medical complications (respiratory, cardiac, urinary). Infection should be mentioned but only to emphasize that without a mesh in place to retain the infection, it has little significance after a Gorman No-Mesh Operation.  It is therefore somewhat ironic that many of Dr. Gorman’s patients are asked to do a special antiseptic scrub of the abdominal wall the day before their No-Mesh operation, but Dr. Gorman believes that even without the worry of big mesh infections, the scrub still is important to avoid other minor infections.
In abdominal wall surgery for very big hernias, a universal complication is the sometimes massive collection of fluid under the skin and fat in the region of the operation. This is called a “seroma”. Dr. Gorman avoids this problem also, by combining the hernia repair with a special esthetic plastic surgery technique called “a modified abdominoplasty” or “paniculectomy”, as described further on (see Section 4.012).
So, Gorman No-Mesh Operations are truly The Gold Standard for avoiding mesh-related and other complications, including those which sometimes cause catastrophic suffering.
The Statistics Showing The High Rate of Cure
The Gorman No-Mesh Gold Standard for hernia surgery has a very high rate of permanent cure. The statistics which prove this most important fact will be presented clearly. First, though, a few points should be made about the definition of “permanent cure”, and the quality of the statistics.
Definition of “Permanent Cure”
Whether an individual’s hernia is permanently cured may not be known until “120 years”. Thus, complete data on everyone will take an impossibly long time to gather. The simplest solution is to declare that the cure is permanent when the hernia has not come back after many years. Dr. Gorman’s statistical results are based on a uniquely long average followup of 9 years, with the results in many patients determined more than 15 years after their No-Mesh Operation. Such results should reflect accurately the permanent cure rate for The Gorman Technique.
The High Quality of The Statistics
The length of followup is not the only critical factor when determining permanent cure rate; the quality of the followup is also extremely important. For example, how many individuals are “lost to followup” and thus excluded from the statistics? It is not uncommon for dissatisfied individuals whose hernias came back to choose to be “lost to followup”, taking with them perhaps the most revealing results. Fortunately, Dr. Gorman maintains an excellent personal relationship with his patients, and, while taking care not to disturb their privacy, he finds that they are universally cooperative.  The results are gathered by Dr. Gorman and his staff by careful telephone interviews every 3 to 5 years, with at least one baseline physical exam over the years. Thus the statistics behind the Gorman No-Mesh Technique are of high quality, being exceptionally complete and accurate.
The Statistical Results Themselves
The statistics showing the success of the Gorman No-Mesh Technique will now be presented. Since there are five types of hernias of the abdominal wall – inguinal, umbilical, incisional, recurrent inguinal and recurrent umbilical – which historically have very different success rates, it has become traditional to give the results for each type of hernia separately. This tradition will be respected here.
Inguinal Hernia Statistics
Eight hundred and forty six inguinal hernias have been repaired by the Gorman No-Mesh Technique for Inguinal Hernias. The average followup is 10 years. There have been 11 recurrences (1%), representing a 99% chance of permanent cure by this Technique. Of course, there were no mesh complications. Of note, the patients were not pre-selected to exclude overweight individuals or very large hernias. Indeed, about 40% of Dr. Gorman's patients have unusually large or complicated inguinal hernias, and/or are very overweight individuals. (Most specialized hernia centers still often refuse to treat such individuals). Thus, the Gorman Technique is indeed The Gold Standard for Inguinal Hernia Surgery, giving a non-complicated and permanent cure of any inguinal hernia in any individual.
Umbilical Hernia Statistics
Dr. Gorman has treated 342 umbilical hernias by his No-Mesh Technique. These were all umbilical hernias which were never before treated. The typical patient has been examined no less than 10 years after the operation to determine its success. Only three hernias (1%) have come back during all these years, making the Gorman No-Mesh Technique 99% successful in permanently curing umbilical hernias. Since there were no complications from a mesh foreign-body, nor any other significant complications for the reasons described above, the Gorman Technique truly sets The Gold Standard of Care for Umbilical Hernias. Additionally impressive, The Gorman Technique for Umbilical Hernias uses only local anesthesia and requires only a few hours hospitalization.
Of note, 61 of the umbilical hernia operations were in women who later had at least one pregnancy during the years following the procedure. Despite their total of 146 pregnancies (!) after their hernia operation, only one hernia  has come back. This proves that the Gorman Technique does indeed restore normal function to the abdominal wall, at the same time that it provides permanent cure of the hernia. These results were recently presented at The American College of Surgeons Clinical Conference in Washington D.C. (October 2010). (See Appendix for Abstract).
Incisional Hernia Statistics
Dr. Gorman has treated 220 incisional hernias with his No-Mesh Technique. The bulge of an incisional hernia can reach the size of an American watermelon, with the hole in the abdominal wall exceeding 25 cm in diameter.  Dr. Gorman’s patients often come to him after trying several times elsewhere to treat their large and complicated incisional hernias, and after sometimes  being told that there is no further cure available for them.  Nevertheless, such patients can be treated simply and safely using Dr. Gorman’s Technique. During the long followup (8 years on average with a maximum of 18 years) 18 hernias (8%) have came back, which fortunately remain small and limited. Thus, The Gorman Technique gives an excellent 92% chance of permanent cure for this most difficult type of abdominal wall hernia. Considering the length and accuracy of the followup, as described above, these results are truly unique. When such an impressive permanent cure is coupled with a total absence of mesh complications, and very low rate of other complications, these results actually are an extraordinary accomplishment in the field of abdominal wall hernia surgery.  They have been invited for presentation before The American Hernia Society in San Francisco in March, 2011 (see Appendix for Abstract). Moreover, many of the female patients have gone on to have normal pregnancies without hernia recurrence, and of course without any problems from mesh foreign body.  Yet another advantage of The Gorman Technique for Incisional Hernias is that in most cases the procedure can be done under local anesthesia, during a short ambulatory hospitalization (see Appendix for Abstract.)  This stems from the superficial nature of the repair which is based on the surface of the muscles, which does not require entering the  abdominal cavity (see Section 5.0).  Of course, an overnight stay of any length is available as requested or needed.  With all these advantages, The Gorman Technique is certainly The New Gold Standard for Incisional Hernia Surgery.
Recurrent Inguinal Hernia Statistics
When an inguinal hernia is treated, it is the responsibility of the surgeon to assure that the hernia does not come back for the rest of the patient’s life. However, most surgeons find that approximately 20% of inguinal hernia operations result in the hernia coming back eventually. This is a “recurrent inguinal hernia”. The surgeon’s responsibility in treating a recurrent hernia is even greater, since another recurrence (a “re-recurrence”) is even more difficult to treat and must be avoided.
Dr. Gorman has treated 116 recurrent inguinal hernias using his No-Mesh Technique. The results after an average of 12 years followup included just 3 (2.5%) re-recurrences. (All of Dr. Gorman's operations are 'guaranteed', so that the few re-recurrences are treated by Dr. Gorman at no cost).
Special Points About The Gorman Technique for Recurrent Inguinal Hernias
A few points should be made about the subject of recurrent inguinal hernias, with respect to the type of the original, failed procedure.
Recurrences Following a Laparoscopic Operation
Usually the original operation which failed is an “old-fashioned” suture operation, but an increasing number of patients are coming to Dr. Gorman with a recurrence or complication after a mesh operation. It should be noted that when the inguinal hernia comes back after a failed laparoscopic mesh operation, the recurrence should best be treated, not by removing the failed internal mesh, which is dangerous, nor by laparoscopically just adding another mesh which compounds the possibility of mesh complication, but by using a “virgin” external approach with the Gorman No-Mesh Technique.
Treating the Rare Recurrence After an Original Gorman Operation
As to the very rare (1%) inguinal hernia recurrence after an original Gorman No-Mesh operation (see Section 3.0423), these recurrent hernias are particularly easy to repair using the Gorman No-Mesh Technique again, which Dr. Gorman does at no cost. This has fully succeeded in all of the six cases where it was done.
In summary, since The Gorman Technique is highly effective for Recurrent Inguinal Hernias, while completely avoiding complications from mesh foreign body, it is indeed The New Gold Standard of Cure for Recurrent Inguinal Hernias.
While some hernias are more immediately dangerous than others, almost all hernias can be life-threatening, and should be treated accordingly. Of course, if your hernia bulge is neither  painful nor barely noticed, it may be hard to understand this fact.
Dr. Gorman’s philosophy about the danger of hernia disease should be explained a bit.
Incarceration of Hernias
All hernias, whether inguinal, umbilical, or incisional, have something very significant in common: the bulging of bowel or fat through a hole or ‘ring’ in the abdominal wall (see Section 2.02). What surgeons strive to avoid is “incarceration” of the bulge by the tight ring. This occurs when the bulge is just too big for the ring, and the hole-like ring of tissue acts to constrict and prevent the bulge from “reducing” or sliding back into the abdomen. At the same time, the pressure on the bulge causes much pain. (If the bulge cannot slide back, but there is no pain, it probably just means that the bulging contents are only adherent to the surrounding tissue and thus immobile, and not actually constricted and incarcerated. This is not dangerous and the hernia is simply “irreducible”. Only an expert surgeon can tell the difference). An incarcerated hernia will do one of three things: it will reduce back into the abdomen, which solves the problem temporarily; it will remain incarcerated with constant pain, and nausea if the bowel is involved; or it will become “strangulated”. The latter is a true emergency, not at all rare, which is life-threatening and requires immediate operation.
However, Dr. Gorman’s philosophy is not to wait for the hernia to incarcerate since even one that has never given a hint of incarceration can incarcerate suddenly and unexpectedly, especially later in life.  This point will be explained further since it is of central importance.
Incarceration Later in Life
Even if a particular hernia has never caused more than the slightest discomfort or sense of pressure or pulling, and then only on rare occasions few and far between – it still is a “bomb waiting to explode”. This is because of the tendency of most people to gradually lose much weight later in life -  and with weight loss the layer of fat lining the abdominal wall melts away. This in turn exposes the hernia hole more, and makes it easier for more abdominal contents to protrude out. The bulge becomes bigger which increases the chance of incarceration. This sequence of events, leading from weight loss to incarceration,  occurs with any type of hernia of the abdominal wall, and can be life-threatening. However, it can be asked, If all this usually occurs only with advanced age, why then treat a “quiet” hernia many decades before? Might not the “early” operation just lead in the meantime to another hernia or complication, especially if mesh is used? In fact, these questions suggest the “raison d’etre” for Dr. Gorman’s No-Mesh Gold Standard Technique. That is, since The Technique has a very high rate of permanent cure and an absolutely zero chance of mesh complication in the future, it uniquely provides the security of a lasting, uncomplicated cure reaching until old age. This, plus the fact that hernias usually cause lots of problems even before old age, suggests that hernias should be treated by The Gorman Technique sooner rather than later.
Diet and Incarceration
Many overweight individuals with very large abdomens have umbilical, incisional or inguinal hernias. The hernias should be treated, and the individuals must lose weight, but in what order? Most surgeons routinely recommend dieting first, since they fear that obesity increases the complications of the operation, and decrease its success. However, Dr. Gorman strongly recommends the opposite – to treat the hernia first, before dieting – for the following reasons. First, as described above, weight loss if done first will cause the untreated hernia to increase in size, become more painful, and possibly incarcerate. This may result in an emergency operation in a medically unprepared, overweight individual, which is a situation to be avoided. Secondly, The Gorman Gold Standard No-Mesh Technique is precisely suitable for overweight individuals. They certainly will not experience any mesh complications, and their obesity does not decrease the safety or success of The Gorman Technique in any significant way. Finally, most overweight individuals have trouble losing weight, so the advice effectively goes unheeded, anyway.  Thus, The Gorman No-Mesh Technique is a very “user friendly” option for overweight individuals.
In fact, Dr. Gorman may even suggest removing excess abdominal fat at the same time that the abdominal wall hernia is repaired. This, besides giving a good esthetic result, also improves the postoperative recovery, as described above (see Section 3.041). His results with the combining of  fat removal with the hernia repair have been invited for presentation in San Francisco in March, 2011, before The American Hernias Society. (See Appendix for Abstract).
The 'Quiet’ Hernia – Unrecognized Incarceration?
There is another important side issue related to Dr. Gorman’s central philosophy that abdominal wall hernias should be treated early to prevent later incarceration. This is the issue of unrecognized symptoms from an abdominal wall hernia. That is, many umbilical, incisional or inguinal hernias which appear 'quiet', are actually causing symptoms that are not recognized as being due to the hernia. These symptoms may be attributed to “gastroenteritis” or unexplained nausea, when in reality they are due to incarceration of the hernia. Such symptoms may recur repeatedly over many months, and can even lead to a vicious cycle consisting of loss of appetite leading to weight loss, which in turn only worsens the symptoms and leads to even more loss of appetite (see Section 4.012). Dr. Gorman finds this to be a common and serious enough problem to warrant its own name, “the chronic intermittent incarceration syndrome”. Many people with hernias unknowingly have this syndrome to one extent or another. A typical illustration of this would be an individual, not necessarily overweight, who had major abdominal surgery in the past. The operation perhaps caused some incisional hernias, one of which contains a small bit of bowel which is incarcerating on and off. This typically results in repeated attacks of “gastroenteritis”, with general abdominal pain and nausea followed by diarrhea. All of this is due to a brief incarceration of the hernia with correspondingly brief bowel obstruction, but because the symptoms are so non-specific, and so short-lasting (perhaps for less than an hour or even a few minutes), the individual and his physicians are not even aware that the cause is the small, localized hernia. This may go on for months and lead to a gradual worsening of general health, that may become life threatening.  During Dr. Gorman’s extensive experience with this syndrome, he has often found that it is present, subtly and to a minor degree, in many people with ordinary umbilical or inguinal hernias. Fortunately, with proper awareness, it is easy to diagnose without time-consuming, invasive and expensive tests.  Dr. Gorman finds that the most effective treatment is simply to repair the hernia in a timely fashion, using The Gorman Technique.
In a certain sense, only Dr. Gorman and his surgical students really need to know about his surgical technique; for anyone else, the main thing is that it works! Sometimes Dr. Gorman is even tempted to describe his technique as “just like spreading butter”, or some such thing! More seriously, though, anyone undergoing a procedure is entitled to complete information about it. Accordingly, Dr. Gorman describes his technique as, “a group of special weaves, each one specially designed to close the hole of a specific type of abdominal wall hernia, and then to reinforce the closure”. A few salient principles emerge from this brief description. First, the group of weave techniques has ultimate flexibility, and fully responds to the differences in size, shape, location, surrounding tissues, etc. of each individual hernia. Secondly, as implied by a “weave”, the repair is quite superficial, only needing to be deep enough in the muscles to close their hole. Thirdly, the weave is not under tension, so it cannot be pulled apart by any activity. This is because any places of potential tension are reinforced as mentioned in the description. Finally, a “weave” implies a “thread”, which in The Gorman Technique is a special nylon thread. The smooth nylon thread remains permanently strong once it is woven in place, and never causes an immunological or foreign body reaction, as well as being totally resistant to infection.
This should provide some understanding of why The Gorman No-Mesh Technique for abdominal wall hernias gives such good results. As to the  actual experience of undergoing such a procedure and reaping its benefits, the following is important to know.
After all is said, the thought of having an operation is frightening, and perhaps somewhat depressing. Dr. Gorman says that he would certainly feel that way. Perhaps because of his empathy, he has taken all steps to translate the technical advantages of The Gorman Technique into a maximally safe and comfortable personal experience, The “Gorman Gold Standard Experience”. This will be described in the following.
The Four Stages of Any Operation
There are four stages that make up the total personal experience of an operation:
(1)  the first 18 hours, which means the operation itself and the immediate recovery period until the following morning;
(2)  the remaining days until a complete return to normal;
(3)  any short-term or long-term complication of the procedure, and
(4)  the long-lasting success of the operation with the potential for permanent cure.
These Four Stages in “The Gorman Gold Standard Experience"
These four stages as they occur in the “Gorman Gold Standard Experience”, are best described separately for each kind of hernia operation: inguinal (single or double), umbilical, incisional, and recurrent inguinal or umbilical.
6.0111  Inguinal Hernias
A unique feature of inguinal hernias is their possibility of occurring “bilaterally”, or on both sides at the same time. Since The Gorman Experience is significantly different for one-sided or two-sided inguinal operations, it will be described separately for each.
(Note: The diagnosis of a one- or two-sided inguinal hernia is made at the pre-operative office visit with Dr. Gorman. If a hernia is present on both sides, a decision to treat them simultaneously is made only after careful consideration and with full understanding. (see Section 6.01112).
One-Sided Inguinal Hernias – The Four Stages in the Gorman Experience
Stage(1):  The First 18 Hours
One need arrive at Assuta hospital or Atidim Medical Center just one or two hours prior to the operation. The admission process is pleasant and efficient.
Anesthesia.       Dr. Gorman always uses local anesthesia when treating one-sided inguinal hernias. His recognized expertise with local anesthesia allows the operation to be done very comfortably. It is not uncommon for Dr. Gorman to be asked at the end of the operation, if it has yet begun! Nevertheless, to assure the most relaxing environment, Dr. Gorman recommends that a sedative or relaxant be administered by his highly professional anesthesiology team.
Going home.       The next thing is, really, just going home! This part of the Gorman Gold Standard Experience is surprisingly good, and occurs within a few hours of the operation. For going home, the comfort factor continues to be high, due to the professionalism of the staff, and to the long-lasting effect of the local anesthesia. The travel home routinely occurs without dizziness or nausea, but instead with a secure sense of well-being. Dr. Gorman or a member of his staff will followup later that evening to answer any questions, and Dr. Gorman remains readily available for calls at any time.
Overnight.        The local anesthesia has an impressive overnight effect, so minimal painkillers, if any, are needed until the following morning.
The second stage of The Gorman Gold Standard Experience now begins, as described in the following.
Stage (2):  The Full Recovery Period
Painkillers and telephone contact.      Beginning with the morning after the one-sided inguinal hernia operation, every individual is encouraged to take an especially effective and safe painkiller around-the-clock. This prevents the general negative feeling common to most operations, and thus makes the recovery phase of The Gorman Experience very tolerable, indeed. Almost daily phone calls from Dr. Gorman or his staff also help secure the desired result of a smooth, confident recovery. Any phone inquiries in the opposite direction are welcomed and encouraged, though the majority find them quite unnecessary. Of course, any significant problems that might arise, though exceedingly rare, are dealt with in any way required.
Return to full activity.       Full activity is attained for everyone within 7 days, and many individuals are fully active a day or two after the procedure. Explicit instructions are given that there for surgical reasons there is no limitation  any time on lifting, exercise or travel.
Followup Office Visit – A  routine followup visit at two weeks is left to the discretion of each individual, and almost all are happy by this time to go on with their lives as if nothing has happened, without the distraction of an office visit. Of course, the telephone lines are permanently left open.
Regarding removal of stitches, an important further contribution to a rapid and smooth recovery is the fact that Dr. Gorman uses a self-dissolving, and in fact ‘hidden’ suture for the skin. Thus, in The Gorman Gold Standard Experience for inguinal hernias there is no need for the sometimes painful removal of clips or stitches.
Stage (3). “The Spector of Complications” (or Lack Thereof)
As discussed above (Section3.0411) , there is absolutely no possibility of complications from mesh after The Gorman No-Mesh operation, and other complications as well are essentially non-existent. So one can be very much at ease with The Gorman Technique: The Gold Standard Experience for Inguinal Hernias does not include the spector of future complications, and the short-term and long-term outlook is uniformly excellent.
Stage (4) Attaining Permanent Cure
As shown in detail in Section 3.04231, attaining permanent cure of the original hernia  is part and parcel of The Gorman Gold Standard Experience for Inguinal Hernias. This, plus the absence of complications, is the reason that The Gorman Technique for one-sided inguinal hernias deserves the appellation “Gold Standard”.
When The Gorman Technique is used for the simultaneous operation of inguinal hernias on both sides (“double hernia”), the gold Standard Experience has an even greater relative advantage, as follows.
Two-Sided (“Double”) Inguinal Hernias - The Four Stages of the Gorman Gold Standard Experience
A two-sided, or “double” inguinal hernia is actually two separate hernias which occur at the same time, one in the right groin, and one in the left groin.
This diagnosis is easily and accurately made during the initial office visit with Dr. Gorman. The decision to operate them both at the same time is made only after careful consideration and with full understanding of the advantages and disadvantages. Dr. Gorman usually advises to do both at the same time, for the following reasons:
(1)  Even if only one hernia is causing pain now, the other one will likely do so in the future when it will need to be treated anyway;
(2)  A single operation for both sides saves considerable time, inconvenience, and expenses, compared to two separate operations. (Note: While a single operation of both sides at the same time is undoubtedly less uncomfortable, and requires less recovery time, than two separate operations, there is of course some real increase in discomfort and recovery compared to a single, one-sided Gorman operation) and,
(3)  For all practical purposes, with The Gorman No-Mesh Technique for double hernias there is not a doubling of the risk of mesh complication or recurrent hernia, as there is with other techniques, since with The Gorman Technique these risks are zero or close to zero in any case.
Stage (1) The First 18 Hours
Anesthesia. Dr. Gorman offers local anesthesia for two-sided hernias, just as for one-sided ones (see section 6.01111-1). Regional (spinal or epidural) or general anesthesia is thus avoided. This is possible because of the wide applicability of Dr. Gorman’s unique local anesthesia technique.
Going home, and overnight. Due to the excellent local anesthetic effort, the personal experience for the first 18 hours after a double hernias operation is very much like that after a single-sided hernia operation (see above6.01111-1). A good sense of confidence and well-being,  which accompanies the individual home, is achieved just as rapidly, and the need for painkillers overnight is equally minimal.
Stage (2) The ‘Full Recovery’ period
Here there is some disadvantage compared to the single inguinal hernia operation, though Dr. Gorman says this is outweighed by avoiding the additional operation and recovery of two separate single hernia operations. Nevertheless, to avoid misunderstanding, The Gorman Experience of a double hernia operation must be compared to the previously described  one-sided operation (section 6.01111-2). In brief, while Dr. Gorman adheres to the same routine of painkillers, and telephone followup, and does achieve a very tolerable recovery experience, it is still rare to achieve full activity as quickly as for the single operation. Thus, perhaps 10% of individuals achieve normal activity within 3 days, about 50% by one week, with close to 100% by two weeks. Everyone is encouraged, however, to be as active as soon as desired after a double operation, since, as with the single operation, there is no surgical reason to limit lifting, exercise, or travel.
6.01112-3, and
Complications (or lack of) and permanent cure
The spector of future complications is as irrelevant, and the short- and long-term outlook is as excellent, for the two-sided as for the one-sided operation, and for the same reasons (see Section 3.0411).
Likewise, the likelihood of a complete permanent cure is hardly affected by the double operation, and is still very close to 100%!
Thus, The Gorman Technique provides The Gold Standard Experience for double inguinal hernias as well.
Umbilical Hernias - The Four Stages of the Gorman Gold Standard Experience
Umbilical hernias, or hernias of the ‘belly button’, vary from very small, pea-sized bulges, to large bulges of bowel through a hole of more than 10 cm.  in diameter. The significance of the individual’s umbilical hernia will be discussed with Dr. Gorman at the first office visit, at which time an operation will be advised if necessary.  As was explained in Section 3.04232, The Gorman No-Mesh Technique provides The Gold Standard for umbilical hernia surgery. Here, the actual personal experience of the umbilical surgery, ‘The Gorman Gold Standard Experience’, will be described.
Stage (1) The first 18 Hours
The anesthesia, going home, and overnight experience for umbilical hernias is essentially the same as for one-sided inguinal hernias, which was described in detail in Section 6.01111-1.
Stage (2) The ‘Full Recovery’ Period
This stage of The Gorman Gold Standard Experience for Umbilical Hernias is identical to that for one-sided inguinal hernias. For a detailed description see Section 6.01111-2.
Stage (3). Complications (Or Lack Therof)
Here there is some divergence from the inguinal hernia experience. This is because of the much higher universal tendency for infection after an umbilical hernia operation compared to an inguinal hernia operation. This is due to the accumulation of bacteria and fungi in the belly button. The Gorman Experience differs mainly in the steps Dr. Gorman takes to successfully prevent such infection. These include a special antiseptic scrub of the entire abdomen at home the day before the umbilical operation, as explained in Section 3.0412.
For further discussion of the absence of mesh-related or other complication in The Gorman Gold Standard Experience for umbilical hernias, see section 3.0232.
Stage (4). Achieving Permanent Cure
Section 3.04232 showed the almost 100% attainment of permanent cure in The Gorman gold Standard Experience of Umbilical Hernia Surgery. It is important to note that the extremely high rate of permanent cure of umbilical hernias occurs even in women who had pregnancies after the operation. This was recently presented by Dr. Gorman at The American College of Surgeons in Washington D.C. (See appendix for abstract of presentation).
Incisional Hernias - The Four Stages of the Gorman Gold Standard Experience
Incisional hernias are the most varied of abdominal wall hernias. As a result, their Gorman Gold Standard Experience is also varied. However, it is possible to make some important generalizations about this type of hernia operation.
Stage (1) The first 18 hours
With The Gorman Technique, even the largest and most complicated incisional hernia needs only a short hospitalization, rarely more than one night’s stay. Many incisional hernia operations can be done by The Gorman Technique on an ambulatory basis! Usually, local anesthesia is perfectly adequate, though this can be supplemented by s spinal, or even general anesthesia. Thus, the initial 18 hours are quite pain-free and comfortable, and going home early is common. It should be emphasized that all this is possible because of the superficial nature of The Gorman Technique, as discussed in Section 5.0. Even with the addition of the combined ‘weight losing’ excision of fat (see Section 4,012) going home the same day is usual.  In fact,  these unique results have been invited for presentation at the Conference of The American Hernia Society in March, 2011 in San Francisco (See Appendix for Abstract).
Stage (2) The ‘Full Recovery’ Period
Between one to three weeks isall that is needed to achieve full recovery after a Gorman Incisional Hernia Operation depending on the size of the hernia, and whether fat excision was also done. Dr. Gorman’s willingness to stay in close telephone contact is very helpful, and undoubtedly contributes to the ease of recovery. However, the cornerstone of the success of this phase is the very effective and safe painkillers used, as well as the secure realization that  The Gorman No-Mesh Technique is a superficial and exceedingly non-complicating procedure.
Stage (3). Complications (Or Lack Thereof)
The Gorman No-Mesh Technique for Incisional Hernias is uniquely free of the spector of complications, as described in Sections 3.041 and 3.04233). This of course plays an important part in The Gorman Gold Standard Experience of Incisional Hernia Surgery.
Stage (4). Achieving Permanent Cure
The 92% chance of permanent cure of incisional hernias is the key element in The Gorman Gold Standard Experience of this type of abdominal wall surgery. Failure, with recurrence of the incisional hernia, is a major universal problem for incisional hernia surgery; thus, an improved success rate surely has been needed.  So, the coupling of a very high likelihood of permanent cure by The Gorman Technique, with its exceptional absence of mesh foreign body complications, is truly an extraordinary accomplishment in this difficult area of abdominal wall surgery.  Indeed, The American Hernia society has invited Dr. Gorman to its next conference in San Francisco, March 2011, to lecture on this accomplishment.   In summary, local anesthesia, short hospitalization, comfortable recovery, with absolutely no mesh-related complications and a high liklihood of permanent cure - these are what uniquely define The Gorman Gold Standard of Incisional Hernia Surgery. 

No comments:

Post a Comment