Fly Well

Hernias are like troublesome neighbors

November 1, 2010

Dr. Jonathan Sackier In 1949 Jerry Lewis, Tony Curtis, and Janet Leigh made a short movie titled How to Smuggle a Hernia Across the Border. Why? I have no idea.

Weird Al Yankovic’s song Living With a Hernia suggests he wanted to smuggle his hernia anywhere away from his body: “Living with a hernia, hurts me bad in a tender location. Living with a hernia, had enough humiliation. Living with a hernia, got to have an operation.”

Hernia is the protrusion of an organ through the wall normally containing it. Picture a troublesome neighbor popping through a hole in your backyard fence uninvited. If he borrows the lawnmower without permission, that is equivalent to a complicated hernia.

Hernias normally declare their presence with painful bulging worsened by standing, activity, or coughing. On examination a doctor may feel the swelling; be able to return it from whence it came, at least temporarily; and detect transmitted pulsation when asking you to “cough, please.”

We classify hernias by frequency, location, and complications. In men, groin or inguinal hernia are most common. During development the testicle descends from the abdomen, dragging the spermatic cord behind—passing through gaps in the abdominal wall, the inguinal canal. While in utero, the entrance and exit of this passage separate, creating an oblique route from belly to scrotum. Abdominal contents can protrude either through the canal (indirect) or through the wall (direct) and violá we have an inguinal hernia.

Nearby, another passageway, the femoral canal, transmits major blood vessels into the leg. Weakness here allows descent of bowel or other structures into a femoral hernia. More common in women and because the femoral is narrower than the inguinal canal, complications occur more often.

You know those white plastic indicators thoughtfully placed in roasting chickens? When cooked, out it pops. It reminds me of a pregnant lady’s umbilicus (or belly button as we medical-types call it), which often pops out near delivery. Such umbilical hernias are common, many disappearing after pregnancy. If the hernia opening is small, complications may be more likely, so medical review is sensible.

Those not blessed with perfect abdominal six-packs (me neither) may not know that the belly muscles meet in the midline as tough fibrous tissue, which sometimes weakens, leaving one with a ventral hernia, if just below the breastbone, an epigastric hernia. An incisional hernia occurs when a surgical wound does not heal perfectly. Newly recognized in athletes, “sports” hernia presents with similar symptoms to inguinal hernia, sometimes without a bulge.

Other hernias include Amyand’s (appendix inside inguinal hernia), De Garengeot’s (appendix inside femoral hernia), Spigelian (abdominal wall), lumbar (back), obturator (pelvis), and several internal hernias such as hiatal and Bochdalek.

Pain and swelling aside, hernia complications include a loop of trapped bowel becoming blocked, necessitating emergency surgery. Alternatively, blood supply may be compromised, causing potential death of a section of gut. If you think a hernia is lurking, see your doctor early.

A baby on board raises intraabdominal pressure causing hernias. Anything increasing abdominal pressure may provoke herniation. Your doctor will consider whether colon cancer causing constipation, enlarged prostate obstructing urine flow, or chronic cough from a lung condition (see “ Fly Well: Physiological Formation Flying,” October 2010 AOPA Pilot) might be significant.

Historically, hernias were treated with a truss—a medieval device that applied pressure to the weakened area. Today, surgical correction is usually recommended, often as an outpatient. Regardless of approach the principles are the same: return the errant organ to where it belongs, remove tissue surrounding the organ and repair defects, either via a regular incision or laparoscopy—a video telescope placed through one tiny incision and operating instruments through other, similarly small incisions. To bridge the gap surgeons use stitches or a nylon-like patch and, with increasing frequency, a biologic mesh, which acts as a scaffold for tissue healing, the implant slowly disappearing over time. No technique works every time and recurrence occurs.

AOPA Director of Medical Certification Gary Crump told me that the FAA requires AMEs to determine the appropriateness of issuing or deferring a medical certificate in hernia cases. In small, unrepaired, asymptomatic defects, where the AME determines that the aeromedical risk of incapacitation is low, a certificate may be issued immediately—as they may also do if the hernia is repaired. Other hernias discussed earlier may have similar outcomes. A good rule of thumb for all pilots when initially reporting a medical condition is to have a letter from your treating doctor at your flight physical, noting you are asymptomatic and require no treatment at this time. A letter from the doctor treating your hernia gives your AME more to work with, often tipping the scales in favor of office issuance rather than deferral.

Hernia is common, problematic, but fixable, so well worth knowing about. See your doctor and heed the words of Weird Al.

Jonathan M. Sackier is an instrument-rated pilot and has been a surgeon for more than 20 years. E-mail the author at jonathan.sackier@aopa.org.

Jonathan Sackier