A hernia is a tear -- an opening in the body that should not
be there. Hernia operations, which constitute 30-40 percent
of all operations done in hospitals, are standard procedures
which have been performed for years. But developments in
recent years have brought welcome news to hernia patients,
especially to women.
Understanding Hernias
Why are such tears so common?
The abdominal wall of the human body goes from the pelvis up
to the rib cage. As those who learn the Daf Yomi recently
learned, this wall holds the vital organs in place. If holes
appear in the wall, vital organs such as the bowel may push
through. This is certainly uncomfortable, and potentially
dangerous as well. Any holes that form should usually be
repaired.
There are three kinds of hernias:
1) "Natural", also known as "congenital" or "umbilical."
Here, a person is born with a hole or else has a weak spot
which eventually opens up. Many children are born with this
problem.
2) A hernia in the groin. This is common in adult men.
3) When the muscle sheet is cut the course of an operation,
such as in an emergency trauma (i.e. car accidents), tumor
removal, appendectomy, or a Caesarean delivery, a permanent
hole may open up in the abdominal wall.
Hernias are often not dangerous, and in most cases there is
no pain. Most people do not need to treat their hernias.
Hernias become a problem when the bowel and/or fat which
protrudes through a hole in the abdominal wall forms a bulge
in the skin. That can cause pain and attacks.
Hernias can sometimes be dangerous. An emergency operation
may be required to save the life of a patient because of
danger to organs strangulated in the hole.
Hernias can also pose a serious problem during pregnancies,
due to the increased pressure then on the abdominal wall.
Why do hernias occur after operations?
There are only three tissues in the body which have a natural
ability to regenerate -- skin, liver, and bone. This means
that if you cut skin, even if you don't sew it up the wound
will contract, come together, and new skin will cover the
cut.
Muscle tissue does not have this fantastic regenerative
property. When it is cut in the course of an operation, the
surgeon must be know how to rejoin those muscles or they will
leave a hole.
Prime Candidates for Hernias
In the case of a Cesarean birth operation, a hernia
eventually develops in approximately 10 percent of all cases.
The muscles open up at some point, usually between 5 months
and a year after the operation.
The largest hernias are usually a result of such Caesarean
operations. In the religious community some women have
several Caesareans.
A person often becomes aware that she has a hernia when she
suddenly experiences sharp pain with a cough. She may feel a
lump at the end of the surgical scar. Many people ignore
these until it is too painful to be ignored and by that time,
the hernia has grown to be a hefty bulge. The sutures have
become undone and the hernia must be fixed and the abdominal
wall repaired.
Mesh Repairs of the Hernia
The standard way of fixing large hernias (of 10 cm and more)
is by using a nylon mesh. The abdominal wall is sewn to the
mesh.
However, meshes bring their own problems. For one, all meshes
shrink 20 percent in the postoperative period. Also although
nylon is not a foreign body which the body usually rejects in
small amounts such as a nylon thread, when a large sheet of
nylon is implanted, it can engender a mild foreign body
reaction. The body sometimes reacts by growing scar tissue
which causes the mesh to come loose and, commonly, causes a
hole.
If a mesh becomes infected, it's almost impossible to treat
it with antibiotics, and patients have to be operated on to
remove the mesh. Then they have to undergo another hernia
operation. In a worst case scenario, it can lead to a
separate operation of excising an intestine.
Today surgical meshes are a billion dollar industry. Since
conferences dedicated to hernia surgery throughout the world
are heavily subsidized by mesh manufacturers, surgeons are
unlikely to look for a substitute. Instead of searching for a
better method that avoids mesh, the industry is just busy
researching and designing new meshes.
A Solution Exists
A serious side effect of meshes is that the mesh inhibits the
expansion of the abdominal wall. Thus women who have large
hernia repairs are advised not to have any more children.
Fortunately, a religious Jew has found a solution for these
women.
Dr. Joel Gorman studied medicine the USA and moved to Israel
in 1979. He studied under internationally-known Dr. Jack
Abrahamson, a South African/Israeli surgeon who authored a
world famous chapter on hernias in a standard surgical
textbook (Maingots' Abdominal Operations) and
pioneered a procedure for fixing hernias without meshes.
Dr. Gorman ran the department of general surgery at Bnei
Tzion Hospital (Rothschild Hospital) in Haifa for 6 years,
and worked 10 years in Mayanei Hayeshua hospital in Bnei Brak
where HaRav Shach was among his patients. He is a member of
the American Hernia Society, and the Israeli Society of Colon
and Rectal Surgery.
Dr. Gorman opened his private Clinic for Reconstruction of
the Abdominal Wall, which has branches in Haifa, Bnei Brak
and Jerusalem. His private practice is devoted exclusively to
the repair of hernias. Dr. Gorman has operated on more than
800 hernias.
Dr. Gorman's Procedure
Dr. Gorman uses Dr. Abrahamson's method for closing hernias
without meshes, and has pioneered a second method of his own.
Both systems have been published in international
literature.
Dr. Gorman uses nylon thread in a special weave which repairs
the abdominal wall both anatomically and physiologically. The
unique weave can withstand the wear and tear of normal life,
prevents the reoccurrence of hernias, fully allows the
expansion of the abdominal wall, and saves patients from the
complications of meshes. Although the general failure rate
for hernia repair is near 10 percent, Dr. Gorman's rate is
virtually zero.
The Gorman method also has a high rate of success with
patients who are obese, who usually have a higher rate of
failure for typical hernia operations.
The professional literature only records three cases of
births following the repair of the abdominal wall in which
there was no recurrence of a hernia. A far larger literature
reports cases of premature labor and miscarriage due to
hernia repair with a mesh.
In contrast, Dr. Gorman's typical case is a woman who wants
to have more children. His impressive record after 20 years
of major hernia repairs is that 42 of his patients
subsequently gave birth to a total of 81 children -- without
the recurrence of a single hernia. Of these 42, two
subsequently gave birth to 5 children, including one to a set
of twins, all delivered by Caesarean section.
Dr. Gorman's dedication to pioneering a hernia repair system
which enables a woman to give birth afterwards, is a direct
outgrowth of his religious beliefs. His clientele is
predominantly religious, since knowledge of his highly
effective operation has spread throughout the religious
community, for whom children are very important.
"My kipah had a big part in my efforts to design a
hernia repair which will enable a patient to have children
afterwards," Dr. Gorman affirms. "Most doctors are not
concerned about this issue." Dr. Gorman says that he simply
considers himself a shliach of Hashem.
Handling Worst-Case Scenarios
Due to his specialty, Dr. Gorman has dealt with cases which
many other doctors will not touch.
In one case, a young mother of two children was hurt in a car
accident. Doctors performed an emergency operation to close a
hole in her intestine and save her life. When the woman
developed a hernia, she was told by her doctor said she
couldn't have more children because the hernia would endanger
her and the child. The young woman heard about Dr. Gorman's
hernia repair, and opted to do it. She subsequently had a
child.
In another case, a patient discovered she had a hernia while
she was expecting. Dr. Gorman advised her to repair the
hernia after giving birth. She neglected to attend to it, and
during the next pregnancy had an acute pain attack a month
before her due date. Dr. Gorman carried out an emergency
operation. One month later, she gave birth normally without a
recurrence of the hernia.
In a third case, an obese patient who previously had seven
Caesarean operations had three separate hernias. She required
an emergency procedure. Dr. Gorman did his repair with only
regional anesthesia. The patient was discharged in good
condition the following day.
A year later, she had an eighth Caesarean. The surgeon told
Dr. Gorman that despite the earlier defects, the abdominal
wall looked completely normal!
Why His Method is Not Widely Known
The world says "nothing succeeds like success" so it is not
surprising that Dr. Gorman's office is busy and his hands are
full. What is difficult to comprehend is why Dr. Gorman's
method has not been widely disseminated in the world due to
its considerable success rate and minuscule rate of failure
and complications.
At a recent convention in Toronto, Dr. Abrahamson's lecture
on Dr. Gorman's methods of hernia repair which do not impede
future pregnancies was chosen among the 30 best lectures from
among 300 to be published in a journal.
Dr. Gorman has been invited to teach in one of Israel's major
hospitals. Dr. Skornik of Ichilov Hospital invited him to
operate on a major recurrent hernia in a chassidic rebbe.
"When I was working in the public hospital system," Dr.
Gorman recalls, "there were two surgical departments in the
hospital. Our team had a virtual 0 percent hernia
reoccurrence rate, and the surgical department next door had
a 10 percent reoccurrence rate, and an even worse rate for
obese patients. The doctors weren't willing to learn our
procedures. This taught me about a doctor's natural
resistance to change."
Although religious medical consultation experts highly
recommend Dr. Gorman, they are reluctant to advocate private
hernia operations when it is a routine operation offered by
Israeli clinics under the HMOs (kupat cholim). Since
his clinic is now private, Dr. Gorman's operations are not
covered by the HMOs. A private hernia operation costs $1,500-
$3,000, which is a heavy expense, although those with
comprehensive medical coverage may have the cost partly
covered.
Dr. Gorman acknowledges this problem of cost. He agrees that
simple hernia repairs do not need the expertise and unique
repair that he can provide. For complicated repairs where,
for instance, the ability to have children is at stake, he
believes the patient should be told about his method and
decide for themselves.
Rabbi Mordechai Eichler, a medical consultant from the Belzer
chassidic community, highly recommended Dr. Gorman to the
Yated. "I think very highly of him and am aware that
he has helped many people. He is pleasant, and very
professional. The people I sent to him were very pleased with
his work and I didn't hear any complaints from them
afterwards."
While Dr. Gorman has worked in public hospitals in the past,
he does not feel that he can offer the quality care and
dedicated follow-up which is vital to him within that system.
For now he maintains private clinics in Haifa, Bnei Brak and
Jerusalem and is not considering reentering the public
system.
Dr. Gorman has plans to publicize his unique method of hernia
repair for the benefit of the broad public. He believes that
by retaining a private practice and showing that it is
fiscally successful will prove to other doctors and hospitals
that they have nothing to lose by adopting his system.
