My surgeon friend asked me today if I preferred a day of straightforward inguinal hernia repairs or a day of dealing with challenging disaster cases. I quickly responded that complicated patients are intrinsically easier because the expectation levels all around are much more forgiving. An inguinal hernia repair is like a cholecystectomy—anything less than perfection is deemed a failure. That, and anatomy and probability dictate that if you operate enough, perfection is impossible.
In the course of a year, I see approximately 250 patients who come to the Lichtenstein Amid Hernia Clinic at UCLA with complications of inguinal hernia repair—neuropathic pain, mesh pain, recurrence, fistula, infection. Invariably, one of the main questions asked is “Was anything done wrong?” This undercurrent has become more prevalent in this climate of mesh fear. While I have read thousands of operative reports and can predict suboptimal operative factors, I always remind patients that 1) surgeons operate with the intention of helping patients; 2) the patient before you and after you who had the same operation are likely doing fine; and 3) complications happen to every surgeon.
What does surgical “science” tell us about optimal technique in inguinal hernia repair? Recurrence rates in the mesh era have dropped into the 2% to 3% range. Chronic pain rates, realistically, are over 5%, affecting patients’ quality of life. Minimally invasive laparoscopic and robotic techniques have matured to provide excellent outcomes with benefits of early recovery and lower rates of chronic pain. However, there is no one-size-fits-all in hernia, with many benefiting from a MIS [minimally invasive surgery] approach, some patients best served with an open Lichtenstein repair, others with a Shouldice tissue repair, and some with watchful waiting.
Especially in hernia surgery, patient outcomes are most significantly tied to the surgeon—the one primary variable that is often uncontrolled in the best scientific studies. Expertise, judgment and proficiency improve outcomes. In inguinal hernia repair, our goal as surgeons is to lower our personal risk for complication to less than 0.5%, but that number can and will never be zero. Whatever can happen in surgery, will happen.
Let me give you an example. A 70-ish-year-old, robust gentleman underwent an uncomplicated outpatient laparoscopic total extraperitoneal repair. Five days later, he was admitted with an ileus, nothing else on examination, labs and CT scan. On postoperative day 7, on rounds, feculent output came out the periumbilical port. Laparoscopy identified fecal leakage in the preperitoneal space with a clean intraabdominal cavity. This was washed out; a laparoscopic right colectomy was performed; and mesh was removed. A Shouldice repair was performed to address the open inguinal canal and hernia. After a prolonged hospital course, sepsis, abscess drainages, rehabilitation, three months later, the patient went home—a fairly horrible course for a “simple” inguinal hernia repair.
In retrospect, the patient reported that his open appendectomy as a young man was accompanied by a long hospitalization with him almost dying from peritonitis. Review of the operative video demonstrated no break in technique or obvious colon injury. A shear injury during dissection of the lateral peritoneal flap likely led to this delayed colon injury with the colon fused to the prior incision. The data and guidelines clearly support a minimally invasive approach; but if only the patient had an open Lichtenstein repair, he would have not been a victim of anatomy and probability.
Even more ironic is that he is my patient at the Lichtenstein Amid Hernia Clinic, where we clearly can perform a pretty good open Lichtenstein. And he is a physican. And a professor. And a colleague. And my friend. While I am still below my aspirational 0.5% complication rate for inguinal hernia repairs, and thankfully I could operatively clean up my own mess, I could have done better. This job is always humbling. All for a “simple” inguinal hernia. As surgeons, we strive for perfection but cannot be perfect, and good hernia surgery demands that we be good general surgeons.
In an ever-specializing field, Hernia is, and always will be, central to general surgery and the bread and butter of most general surgeons’ practices. Herniorrhaphy is one of the first operations that we teach our interns, the first cases that we book as an independent young attending, and by volume, the most common operation that we as general surgeons perform for patients. “It’s just a hernia,” until it’s not. Simple procedures can quickly become complex, and our complicated cases in Hernia become more challenging as we work to provide patients with durable repairs, functionality and better outcomes.
The field of Hernia has transformed and expanded to encompass a broader complexity of disease and variety of techniques. With novel techniques, advances in prosthetics, robotic assistance, advanced reconstructive operations, enhanced recovery pathways and continuous quality improvement initiatives, there is more for surgeons to learn than ever. Abdominal wall reconstruction; component separation techniques; minimally invasive and robotic surgery; diaphragmatic, perineal, lumbar, flank, parastomal hernias; athletic pubalgia; chronic groin and abdominal pain; and management of enteric, infectious and inflammatory complications of hernia clearly demonstrate that the state of the art is anything but simple.
We have made significant strides reducing recurrence rates, decreasing morbidity and mortality, shortening hospital stays, dropping infection rates, and generally improving outcomes. With such rapid progress and change, never has it been more important to optimize patient outcomes though education, standardization of techniques, and research to provide evidence that progress translates to better outcomes and value. The Americas Hernia Society (AHS) is leading this change, carrying out our missions of education, advocacy, research, outreach and stewardship.
The AHS WISE (Web Information Social Media and Education) initiative, led by Drs. Vedra Augenstein, Conrad Ballecer, Megan Nelson and Sal Docimo, and our robust Education Committee assembles incredible state-of-the-art lectures accompanied by biweekly moderated sessions on the International Hernia Collaborative Facebook page for our members and the Hernia community to interact. After a pandemic hiatus, our Hernia Compact Program for residents and fellows, Open to Robotics Labs, and Advanced Surgical Skills Hands-on Labs have resumed to help surgeons to adopt new techniques and skills in a mentored fashion.
The AHS has been tirelessly working to advocate for better, more accurate procedure-specific coding and compensation for Hernia. Led by AHS governors Drs. Scott Roth and John Fischer, we are well into the years-long process to join the RVS Update Committee, advocating to fairly and appropriately value the complexity, diversity and breadth of the services that hernia surgeons provide.
The AHS continues to promote the cutting-edge research essential to move our field forward. In collaboration with our partners at the Abdominal Core Health Quality Collaborative, the AHS annually awards five Hernia and Abdominal Wall research scholarships at the annual meeting, along with the AHS Women Issues in Hernia Surgery Research Scholarship founded by Dr. Shirin Towfigh.
We actively are working to recruit new, diverse, talented voices to participate in and lead the AHS. As the umbrella Hernia Society for the Americas, we enjoy and promote robust engagement with our Latin American and Canadian colleagues and our world Hernia partners. We continue to work for greater opportunity and equality in our field, society and communities for all our members, surgeons and patients alike. We are proud of the steps that have been accomplished at the AHS to keep our society open and inclusive, while understanding there is much more work ahead to live up to our hopes and expectations.
The AHS Foundation continues to promote charitable and humanitarian outreach with a stronger, formal relationship with Hernia Repair for the Underserved, the charity started by AHS founders Drs. Chuck Filipi, Arthur Gilbert and Bob Fitzgibbons, and includes many of our AHS past presidents and leadership. Now more than ever, we are reminded of the importance of helping one another and advancing our field by taking care of the underserved and serving our neighbors here and abroad.
Without hyperbole, the last year has been perhaps the most disruptive, challenging and transformative in most of our personal lives and professional careers. Despite this adversity, we find the field of Hernia at an exciting time. The next chapter in Hernia and Abdominal Wall Surgery will be exciting. We at the AHS will lead this change and help define our growing field. Hernia is inherently a collaborative, collegial, friendly discipline in which surgeons are happy to share, mentor and raise the bar for all so that we can all do better for our patients. We can never be perfect, but we can work together to continue to try. I invite each of you to join the AHS, actively participate in your society and help us lead this exciting change.
After a long COVID-19 winter, on behalf of the AHS, Dr. Jeff Janis our program chair, and the Program Committee, we are excited to invite all of you to meet next month in Austin, Texas, in person, for the 2021 AHS annual meeting.
Dr. Chen is a professor of clinical surgery at the David Geffen School Medicine at UCLA, the director of the Lichtenstein Amid Hernia Clinic, both in Los Angeles, and the president of the Americas Hernia Society.
This article is from the August 2021 print issue.
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