Today was hernia day in the office. That wasn’t the intent; it was just the way the referrals came in. Four out of five new patients this afternoon had either complex or recurrent hernias. I seem to have acquired a reputation as the go-to guy for difficult hernias. It wasn’t something I sought out. In fact, it’s something I wouldn’t mind losing. I don’t know if I get these cases because I get good results, or if it’s just a matter of, “Hey, let’s call Davis. He’ll operate on anything.”
Hernia surgery is one of the most underrated aspects of general surgery. A hernia repair is likely the first real operation you do in training, usually as an intern. Both the patient and the surgeon regard hernia repairs as relatively minor procedures. After more years than I care to think about in this business, I have come to appreciate the herniorhaphy as an operation that is simple and elegant in its conception and sometimes devilishly difficult in its execution.
A hernia is nothing more than a gap or hole in the abdominal wall, but there are also natural gaps between muscle groups and normal openings in the wall that allow structures to pass through. Spontaneous hernias tend to occur through these areas, the most common locations being the groin and the umbilicus. Adult spontaneous hernias should be repaired with some kind of reinforcing mesh or tissue. Direct repair with suture alone has a 15% to 30% risk of recurrence. A huge VA study in the late 1980’s proved the superiority and safety of mesh repairs, and it has been the standard of care ever since.
“I have come to appreciate the herniorhaphy as an operation that is simple and elegant in its conception and sometimes devilishly difficult in its execution.”
Incisional hernias are more complex. As the name implies, these occur through old incisions either due to infection or just poor wound healing. Under the best of circumstances, a midline abdominal incision has a 10% chance of giving rise to a hernia, often many years later. Any first repair has about the same 10% risk of recurrence. Any subsequent repair adds another 10% risk, that is, 20% for a second repair, 30% for a third repair, and so on. The risk of recurrence tops out at about 50%, but at that point the statistics have little to do with individual patients. Fixing these hernias can be particularly challenging. Fixing them after a couple of recurrences can be downright intimidating.
One of my new patients has had ten prior abdominal operations and three prior ventral hernia repairs, none by me. She’s as healthy as a morbidly obese 60 year old can be—no known heart disease, no diabetes (surprising), and no pulmonary disease. But her weight alone makes her risk of recurrence high. Several surgeons have already refused to operate on her. (See the first paragraph of this post. Yes, I’m a sucker).
At the recent 2014 meeting of the American Hernia Society in Las Vegas, a consensus panel of experts recommended saying ‘No’ to patients who would not stop smoking and lose weight before a complex hernia repair. They make their patients show that they haven’t smoked for 6 months and that their BMI is less than 50 kg/m2.
My patient doesn’t smoke. There is, however, no expectation that she will lose substantial weight, so requiring that before fixing her hernia is unrealistic. The proposed guidelines may work in a big academic center or a multispecialty practice where the surgeon is salaried and has an assured referral base. For the solo private practitioner, turning away otherwise reasonable risk patients on the basis of weight alone is a nonstarter. I know the statistics about complications of component separation in the obese. I also know the abysmal statistics of meaningful weight loss in these patients, especially if they are over 50. I have advised her of the risks and suggested she lose the weight. She indicated that this was what the other surgeons had said; that she hadn’t been able to lose weight in 2 years of trying; and that her hernia was now so big that she couldn’t wash her own perineum. So we will proceed with surgery sometime in the next few weeks.
She will need what is called a component separation. We split the abdominal wall into its component muscle groups. We repair the hernia defect with some kind of mesh or artificial tissue and them move the separated components toward the midline to close the abdominal wall. The exact procedure will depend on the strength and integrity of what muscle remains in her abdominal wall.
I was realistic her. Her overall risk for another recurrence, no matter what how good a job I do is 40% to 50%. I have no clear idea what I will actually do once we get into the operating room. This is a situation where I literally make it up as I go along. I may be able to find enough sturdy tissue to do a repair. I may need to reconstruct part or all of her abdominal wall with a human tissue graft—cadaver skin that has been processed into a leathery patch we can use to repair defects where the bowel or viscera will be exposed to the patch. Synthetic mesh and bowel are a bad combination leading to scarring, erosion, perforation, and infection.
Every surgery like this is a new adventure. And as Zane Grey said, “Adventure is just another word for trouble that smart people learn to avoid.” I think maybe I should listen to him more often.
What would you do given the situation?
Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.