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Clinical Data on Small Abdominal Wall Hernias
I’ve been looking around at all the (generally insufficient and poor quality) clinical data on surgical repair of abdominal wall hernias. I pinged Ben Poulose because he’s coordinating the collection of a fairly large volume of data, and Dr. Towfigh’s name came up.
I have a 4mm epigastric hernia 1.5″ above the umbilicus, it’s hard to detect even palpitating, certainly doesn’t show to the surface, and will at worst flare up to a 2-3 on the 1-10 pain scale. I’m 6’1 167lbs and have ~26.4% abdominal fat (DEXA scan @ 29, total BF @ 25% then, probably down a bit from there since the scan).
I’m also in touch with the author of this: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273884/ – it’s for a sports hernia but I specifically asked him about abdominal wall hernias and he reports success with them as well, using the above protocol.
The thing that bothers me abut a surgical approach: no one doing surgery seems to be tracking:
[ul]
[li]gender[/li]
[li]Height[/li]
[li]Weight[/li]
[li]Size of defect[/li]
[li]Location of defect, (including globally unifying the nomenclature)[/li]
[/ul]in the data. All the studies I’ve seen are tracking defects that range from 0.5cm to 10cm+, which obviously require completely different surgical approaches, treatment plans etc. I’m also surprised not to see any discussion of fat loss and reduction of hernias. Depending on the mechanics of the pressure at the site, it seems at least reasonable to assume that reducing the volume of abdominal fat would reduce that pressure. I’m going to get down to ~10% total BF and play with https://www.google.com/search?q=naiuli+kriya in an ultrasound room to see if anything changes. (and hey, I’ll be at lookin’ good @ 10%, so why not!)
There’s also Shouldice/Modified Shouldice, simple sutures, mesh-behind-rectus, mesh-on-top, etc – I don’t see any summaries of these methods used on abdominal wall hernias, so am loathe to just pick a surgeon and hope.
I’m looking for anyone who does have a practice of collecting detailed data on their patient outcomes, so they can show me success rates with defects similar to mine in body types similar to mine. I’ve been surprised not to find that level of record keeping with a few offices I’ve contacted.
Am I going about this wrong?
Thanks
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3 Replies
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Clinical Data on Small Abdominal Wall Hernias
I believe most surgeons would perform a simple primary suture repair for such a small epigastric hernia. If it can be reached from the umbilicus (belly button), then the incision can be hidden in there.
Most surgeons place mesh for most umbilical or epigastric hernias, nationally. And studies show that mesh repair is always superior to non-mesh for this problem, in terms of recurrence. However, the smaller the hernia, the less the superiority of mesh in reducing recurrence. In my practice, I do not routinely place mesh if these hernias are under 2cm.
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Clinical Data on Small Abdominal Wall Hernias
What surgical approach do you recommend to your patients for small hernias? Do you have any published data on outcomes?
Also, I wouldn’t have someone local perform surgery unless they were among the best nationally. I would want to be a boring yawner among more complex problems for an experienced surgeon 🙂
Also, I recognize that deterministic outcomes in complex systems are hard to come by, but outcome data is fairly easy to track.
Thanks for taking the time to respond!
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Clinical Data on Small Abdominal Wall Hernias
First, let me assure you that almost all databases that I am aware of and publications that I have seen and those that I also perform include patient demographics, e.g., gender, height/weight. The height/weight are often reported as body mass index (kg/m2). That is pretty standard.
That said, you are correct: there is no formula where you can plug in your own info and it will spit out the risks and benefits tailored to your needs. Medicine is not a perfect science by any means. You may find me the same exact findings in a different patient and perform the same exact operation and the outcome may be different. Every patient is truly different. Now, statistically, the risk/benefit may be the same, but the outcome per patient will be different.
Dr. Bruce Ramshaw is a whiz in this concept of “complex systems” and has been able to show that implanting the same mesh in two different people, for example, can have drastically different outcomes at the mesh and cellular level.
Hopefully, one day, we can tailor each patient’s care to their own specific needs and body’s interactions, maybe even by genetic evaluation. Today, we cannot do that. Most of us who are interested in this topic, however, do have our own database and do publish. Also, if you go to the americanherniasociety.org website, they have a database that many surgeons also participate in, called the AHSQC. You can find out which surgeons near you participate. Lastly, there are other national databased with the American College of Surgeons, NSQIP, etc., that some surgeons participate in.
With regard to your 4mm hernia: if you are symptomatic, then I recommend repair. I also do not recommend mesh implantation for such a small hernia.
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