News Feed Discussions HERNIA FIELD TURNED UPSIDE DOWN

  • HERNIA FIELD TURNED UPSIDE DOWN

    Posted by pinto on May 20, 2023 at 6:28 am

    Surgery load for surgeons— whether high or low– is vital: “Several studies and analyses have found that physicians who do not perform a procedure frequently have higher rates of post-surgical complications and deaths” (Varn, 2020). It seems intuitive that highly experienced surgeons both by their breath of career and their frequency of surgery are preferable to surgerons with much less experience. Shockingly I found a highly touted medical study of 22,000 cases aimed to provide data for chronic pain etc. was fully based on surgeons with low-volume loads (50 or less a year).
    https://herniatalk.com/forums/topic/patient-reported-rates-of-chronic-pain-and-recurrence-after-groin-hernia-repair/
    Even the most experienced were only doing approximately 5 hernia surgeries a month. Specialists talked about here at HT do at least 3x that!

    I myself am new to the subject of herniae so have read few medical research studies, but I believe that the low-volume study referenced is probably unique for including surgeon load as a factor of success. And because most studies are likely based on populations found in general hospitals, we can deduce that many of these studies are low-surgeon-load studies as well. If true, it turns the hernia field upside down.

    Assuming that Varn’s (2020) findings are valid, then what we thought about chronic pain rates and recurrence rates must be re-thought in terms of what can be expected by highly experienced specialist surgeons. The lookout especially for pure tissue repair never looked better!

    It would be very useful for HT if Members who have had poor outcomes of surgery report to us how experienced their surgeons were. This might not be easy to know. As a starter, it would be helpful to know if the surgery was performed at a “general hospital.” Could it be that many of the terrible outcomes reported here come from GHs? I know some do not so I am not surprised that some are associated with specialists as well. (I call a “specialist,” one who is in private practice solely doing hernia surgeries.) Please share what you can tell us.

    • This discussion was modified 9 months, 2 weeks ago by  pinto.

    Patient-reported rates of chronic pain and recurrence after groin hernia repair

    pinto replied 9 months, 1 week ago 4 Members · 6 Replies
  • 6 Replies
  • pinto

    Member
    May 21, 2023 at 8:15 pm

    Watchful, I love that expression, black art. Bravo. Interestingly the black arts ignored by the study could actually number 1,000 even more per the article. Rather than practical reasons, I bet the black arts were excluded for political reasons (in mesh). (Of course I estimated the figure because the authors did not disclose the exact number of tissue repair cases found; rather we must surmise them.)
    Herniated, that’s useful information about Shouldice. We’ve also I believe heard Dr. T. say similarly for robotic surgeries. You need a highly, highly experienced surgeon. I shudder when I think how I might have gone blindfolded in allowing my local general hospital surgeon do one on me, someone I’m certain was a recently minted doctor.

  • Herniated

    Member
    May 21, 2023 at 9:44 am

    It has long been recognized that the recurrence rate for Shouldice repairs is much lower for high volume surgeons than it is for low volume surgeons. This paralleled its reputation as a difficult surgery to master. So much so that one of the benefits touted for the Lichtenstein Repair of Inguinal Hernia using mesh was that successful repairs could be routine for surgeons with minimal experience.

    To give a sense of time: I.L. Lichtenstein (1986) Hernia repair without disability.

  • pinto

    Member
    May 20, 2023 at 4:55 pm

    The study might be of much interest to people of Sweden, fine. But I presume HT Members are from all corners of Earth and the majority of which interested in high-surgeon load hernia specialists. You can quibble about the numbers all you want but it is very likely that a vast majority of surgeries done were by low-volume load surgeons, loads distinctly less than those of the specialist surgeons discussed at HT as choices for a surgeon. Given that the hernia specialist is relatively new as a field, there is likely a dearth of data based on high-load specialty surgeons. Again if Varn’s (2020) point valid, then a re-thinking of complication rates in hernia surgery is warranted.

  • MarkT

    Member
    May 20, 2023 at 12:26 pm

    I discussed this study at more length in the other thread. I’m not sure what has been ‘turned upside down’. Much research points to inexperienced surgeons failing to replicate the outcomes of high volume specialists.

    “Shockingly I found a highly touted medical study of 22,000 cases aimed to provide data for chronic pain etc. was fully based on surgeons with low-volume loads (50 or less a year)”.

    It is not correct to assume it was ‘fully based’ on low-volume, 50 or less. The study also needs to be taken in its proper context. Per the paper, the data is based on the Swedish Hernia Registry, which includes almost 98% of all repairs performed in the country during that time period. This study is therefore quite relevant to hernia patients in Sweden.

    It is not relevant to us on this forum, because we will all choose (or have chosen) a high-volume specialist.

    “Even the most experienced were only doing approximately 5 hernia surgeries a month…”

    We don’t know that from what is presented in the study. Knowing the median is only knowing the middle data point. Alone, that does not reveal the range of the data or the shape of its distribution.

    Even taking this study in its proper context, it is important to note that there is only a 1yr follow-up period, which we know is inadequate for judging long-term complication rates of chronic pain and recurrence. The prevalence of complications is therefore almost certainly underestimated (and probably by a wide margin, based upon other research that suggests a significant % of complications present years later).

  • MarkT

    Member
    May 21, 2023 at 2:07 pm

    Of course this study needs to be taken into its proper context…as does every study.

    This is science…it is important to ‘quibble about the numbers’ and not make assumptions. There can be a world of difference between two data sets with the same median, depending upon the range of their data and the shape of the distributions. That is simply a fact, not merely my opinion.

    If the majority of surgeons covered in that study are indeed low-volume, with only a very small number of higher volume ones, then it would speak precisely to my stated concerns with how the variable of surgeon volume was treated. If there are zero high volume, and the distribution of annual volume is approximately normal, then it is *much* less of an issue. The point is, we don’t know from what info is provided.

  • Watchful

    Member
    May 21, 2023 at 1:46 pm

    Right, but this study didn’t include tissue repairs, which are admittedly a black art that has always been difficult, and thus almost gone from the world now.

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