On the Spot: The Art of Herniology 2020

For this year’s “The Art of Herniology,” I have created a mix of topics within the general focus of hernia surgery. I thank all of the participants for their contributions to this column—especially during a busy holiday season. Their hard work and time make this a compelling installment, in which only one of five statements finds any kind of consensus. Don’t forget to check out the Gut Reaction on page 14 as well for some quick candid thoughts from these contributors.

Feel free to email me at colleen@cmhadvisors.com with any ideas for debate in hernia and other areas of general surgery. Thanks for reading!

—Colleen Hutchinson

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Colleen Hutchinson is a medical communications consultant at CMH Media, based in Philadelphia. She can be reached at colleen@cmhadvisors.com.

There is a critical gap between the surgeon MDs who take care of patients and the MDs who administrate.

Dr. Voeller: STRONGLY AGREE This is a topic of discussion in our lounge all the time. Many times those surgeons who administrate were never good surgeons or could not take the stress of surgery, thus their move into administration. What’s that phrase? Those who can, do; those who can’t, teach or administrate. During my 32 years as a busy practicing surgeon, I have seen several surgeons leave careers and go into administration. It takes a special person to be able to walk this tightrope. Unfortunately, too often these surgeons totally forget what it’s like in the trenches and I tell them they should remove the initials “MD” from their coat and name tag. They forget where they came from and totally adopt the administrative mindset, which is totally different from a practicing surgeon’s mindset. The good ones don’t forget where they came from and don’t become 100% an administrative puppet. Unfortunately, these are the ones who eventually get fired for not drinking the Kool-Aid. When you’re getting paid to be an administrator, you have to do what the administration wants you to do, or else.

Dr. Prabhu: ON THE FENCE I think it’s tough to pigeonhole people into categories. That said, we can likely all think of examples of physicians who transition completely out of clinical practice into administration and subsequently not only lose touch with the challenges faced by their clinical colleagues, but also sometimes turn a blind eye to those issues. Those who maintain clinical practice while also engaging in administrative roles may be able to maintain a broader view and close that gap a little bit. At the end of the day, however, someone has to run the hospitals and outpatient practices, and it is my belief that clinicians should have a heavy hand in that.

Dr. Pryor: DISAGREE There may have been a gap before, but I think it is narrowing. Many surgeons, myself included, are pursuing advanced degrees to arm them for business discussions and administrative roles. By adequately preparing and participating in both clinical medicine and administration, we can be fluent in the language throughout health care. The newest generation of administrators will be much more comfortable with the issues clinicians face in day-to-day patient care.

Dr. Ciocchetti: TOTALLY AGREE! The critical gap is that there are too few surgeon MDs in administration. We have allowed our voice to be shushed for far too long. It feels easier in the short term to put our heads down and take good care of patients than to try to change a broken system. However, without input and active work from surgeons, we are left out of critical decision making. I see the purpose of an MD administrator as someone who can bridge the gap between the business administrators and those who take care of patients. Our job is to ensure that quality patient care and the well-being of health care workers are the primary outcome, as opposed to a primary focus on financial metrics.

Dr. Poulose: ON THE FENCE This varies considerably based on the values of an individual surgeon-leader and how they got there in the first place. I believe the most respected and effective surgeon-leaders are the ones who are excellent clinical surgeons first and everything else second, including administration, research and education. True leadership characteristics are becoming increasingly valued in surgeon-leaders rather than individual career successes, such as the ability to obtain federal research funding. It is critical that surgeons “in the trenches” support and foster effective surgeon-leaders who can then advocate for them, their individual situations, and, ultimately, their patients. We as surgeons have been traditionally divided by our own intense competition on multiple levels. We should work together for common goals and support each other.

Generally, the benefits outweigh the risks of placing prophylactic mesh.

Dr. Poulose: ON THE FENCE It’s a balance between the issue you are trying to address prophylactically versus the risk involved. For parastomal hernia prevention at the time of ostomy creation, there are reasonable data to inform us that prophylactic mesh placement has benefits and acceptable risk, given the very high rates of parastomal hernia formation. I do advocate the placement of retrorectus midweight macroporous polypropylene mesh at the time of stoma creation. For hernia prophylaxis during laparotomy in general, I do not think there are sufficient data to support the use of prophylactic mesh. We need large prospective studies to establish the level of harm involved in these situations, and then make a responsible decision as a community whether the benefits are justified. How about everyone just learn to close laparotomies using the small bites technique and we incentivize it? That might be the best start in terms of supporting hernia prophylaxis.

Dr. Voeller: AGREE I think the Level 1 data certainly support prophylactic mesh placement. This is something we have been doing in our practice for quite some time, even before the studies were published, since we repopularized the onlay use of mesh in properly selected hernia patients. I think the small risk for seroma or infection, which can be controlled with negative pressure therapy, far outweighs the risk for major hernia repair.

Dr. Prabhu: DISAGREE We know from the study by Kokotovic et al that the cumulative risk for reoperation for a mesh-related complication is almost 5% for patients who had a hernia and underwent a mesh repair (JAMA 2016;316[15]:1575-1582). In the absence of a stoma, I am not convinced it is reasonable to put a patient without a hernia at risk for a mesh-related complication.

Dr. Pryor: ON THE FENCE For high-risk wounds, the use of prophylactic mesh can reduce the risk for hernia or reoperation. The key is what is high risk and selecting the right patients for mesh.

Dr. Ciocchetti: DISAGREE I don’t believe prophylactic mesh makes sense as a general rule, even in high-risk patients. Although incidence of incisional hernia can be reduced, several studies show an increased risk for post-op seroma, post-op chronic pain and delayed wound healing. Also, the number needed to treat is too high to justify the cost from my perspective.

Dr. Ciocchetti: DISAGREE I don’t believe prophylactic mesh makes sense as a general rule, even in high-risk patients. Although incidence of incisional hernia can be reduced, several studies show an increased risk for post-op seroma, post-op chronic pain and delayed wound healing. Also, the number needed to treat is too high to justify the cost from my perspective.

All hernia surgeons should be engaged in a quality improvement program for hernia care.

Dr. Prabhu: AGREE If surgeons are doing a high volume of hernia repair, I think they should engage in a quality improvement program. I believe it is part of our responsibility as surgeons to make sure our patients are getting the best operations they can, and therefore the outcomes hopefully will follow. I don’t think all surgeons need to be academic, but they should contribute their data from their cases so we can figure out best practices. Coming to quality improvement meetings can also be a great way to engage with the surgical community and to learn from each other.

Dr. Pryor: AGREE, although I’m not sure it has to be a formal national program. I do think surgeons should know their outcomes and track their patients so we can continue to learn from our mistakes and successes to improve surgical care.

Dr. Ciocchetti: AGREE Quality improvement should be part of every surgeon’s practice.

Dr. Poulose: AGREE I think everyone knows my bias on this one! It’s a different kind of surgeon who takes an active involvement in the quality improvement process. With hernia, quality of care needs to be assessed on a long-term basis. We should ask: Two years after an extensive abdominal wall reconstruction, is my patient better off? Three years after inguinal hernia repair, what’s my patient’s activity level, and is there chronic pain? Our health care system in the United States isn’t well equipped to assess these long-term goals. We are too focused on getting the patient into the OR, checking on them once a few weeks later, and then moving on to the next patient. Quality improvement efforts have focused largely on short-term (30-day postoperative) goals because that’s about all we can measure easily. I would consider that more the “safety” of hernia repair, which is very important. But true quality comes in long-term assessment, especially when devices are used that are meant to last for years. For that, participation in long-term quality improvement programs is key.

Dr. Voeller: AGREE We certainly all can improve. We all are now being reimbursed based on quality metrics. The Americas Hernia Society Quality Collaborative (AHSQC) makes it very easy to be involved in a quality improvement program. If one has the time and personnel to accomplish the paperwork, it is certainly to their benefit as well as the patients’ benefit. If you let the nonsurgeons decide what your quality metrics are going to be—as is often the case in the hospital today—you will be losing the battle. The nonsurgeons who decide your quality metrics have no idea what true quality looks like, and the metrics they come up with have nothing to do with true quality improvement.

Prescribing opioids should be at the discretion of the surgeon.

Dr. Prabhu: ON THE FENCE I like the idea of having some general guidelines around best practices for prescribing narcotic pain medication. I also think surgeons should have some discretion in how much we write. In our current environment, I do think the federal government should also be involved with appropriate messaging to the public about narcotic pain medication. In the current iteration, surgeons are responsible for keeping their patients satisfied and for not overprescribing pain medications. There is a need for both, but the messaging so far has served to create a more challenging environment for surgeons, who, by default, will often have unsatisfied patients when their demands for opioids are not met. I am personally very conservative and have significantly decreased my prescribing of opioids, as have my partners. Still, patient expectations have yet to catch up, and I strongly believe that they should receive that messaging from the Centers for Medicare & Medicaid Services.

Dr. Voeller: AGREE The surgeon knows what is involved in the surgery. No one else has the same knowledge. I am fine with a pain service being involved for hospitalized patients but the surgeon also should have a significant input since only they know what is involved in the surgery. For outpatient surgery, the surgeon is in charge of pain relief, and if opioids are indicated then that is at the discretion of the operating surgeon.

Dr. Poulose: AGREE The surgeon knows the individual situation of the patient and can recommend the use of opioids, if needed. Surgeons should also know that there are many opioid-sparing pain management protocols that can be used to minimize the use of opioids in most elective operations. These include Michigan OPEN (www.michigan-open.org) and the AHSQC Opioid Reduction Initiative (www.ahsqc.org/ patients/ opioid-reduction-initiative).

Dr. Ciocchetti: ON THE FENCE While I think we must be given the latitude to treat our patients in the way we see fit, pressures from the outside have influenced our prescribing patterns for a long time. Surgeons should be able to prescribe opioids when necessary but should also use nonopioid medications as adjuncts. Education on nonopioid pain management, orders sets that include nonopioid medications, and acute pain teams are helpful in minimizing narcotics in the hospital.

Dr. Pryor: DISAGREE There has been a major shift in opioid prescribing over the last several years as we have gained awareness about addiction. I was shocked when I learned that 7% of opioid-naive patients will become addicts after receiving narcotics for elective surgery. If we cut back the number of pills given and avoid opioids as far as possible, we can reduce this number and make a real difference in a public health crisis. Regulations that help all surgeons follow these new guidelines can help to minimize problems with addiction.

The use of a falciform ligament flap in paraesophageal hernia repairs is a tool that should be in the toolbox of every hernia surgeon.

Dr. Pryor: AGREE! This technique has been described and published with excellent results. I find it straightforward to employ. By creating a pedicle flap of native tissue, the surgeon can reinforce a primary repair while avoiding mesh. I have also used a falciform flap to cover a synthetic mesh on cases where I felt mesh couldn’t be avoided. This should help to protect the gastroesophageal junction and minimize mesh complications in this area.

Dr. Poulose: AGREE Anytime autologous tissue can be used to assist with repairing a hernia, that technique should be in your armamentarium and used when appropriate. While a falciform flap may not be needed in most hiatal hernia repairs, it can be useful in more complex repairs where an additional tissue buttress is needed.

Dr. Prabhu: DISAGREE. This is a bit overstated for a technique that really doesn’t have much objective evidence to support its use. There are no trials to suggest that a falciform flap improves short- or long-term outcomes. First, I’d like to see some outcomes associated with it. In absence of that, it’s an anecdote.

Dr. Voeller: AGREE I think any good foregut surgeon should have this in their toolbox, but I think it actually does nothing and I never use it.

Dr. Ciocchetti: AGREE A great option when you need it.

Dr. Voeller: AGREE I think any good foregut surgeon should have this in their toolbox, but I think it actually does nothing and I never use it.

Dr. Ciocchetti: AGREE A great option when you need it.