Is there any hernia repair surgeon combo

[MeshorNot]

That offers the best chance of success? Honestly guys I am completely stumped. Maybe it’s from hanging around hernia boards but all I see is horror story after horror story. Mesh nightmares shouldice chronic pain stories desarda failures. There simply has to be a mostly better way to get hernias repaired. But what the heck is it? Harris says lap mesh. Tomas says desarda is least associated with pain. Kang says his repair is best due to minimal invasion and low recurrance rates. Reinhirn says his technique is best and shouldice is the best no mesh repair. So what the heck is the best repair? The studies offer zero clarity. The doctors all push their own repairs. But there must be a consensus. And who is the best surgeon to do it ??? Does anyone get a pain free complication free result? It sure doesn’t seem like it

[MeshorNot]

I would love to hear if you go to Conze for a shouldice your odds are very good you will have a pain free repair. Or if you got to Tomas for desarda it’s very unlikely you will have any issues. But no one can say this. There simply has to be a repair and a surgeon that gives you the best odds. I think in life it’s best to be a dumb ass. Got to your primary care go where he says get mesh slapped in open and go back to life. When you start looking into this you realize there are zero good options.

[Watchful]

There’s no answer to this question for many reasons, including the fact that different approaches are best for different cases. For example, it’s quite possible that Shouldice was the best procedure for MarkT, Lichtenstein would have been best for me, and lap mesh would be best for someone else. Also, if you’re looking for a surgeon/procedure combination with a perfect track record, you’ll never find it.

Like I said many times, why not just go to Conze if and when your hernia recurs, and let him decide what to do (Shouldice or Lichtenstein). For Lichtenstein, there are a number of very good options in the US – you don’t even need to go abroad.

No one can guarantee you won’t get a bad result with any of these, and your local general surgeon referred by your primary care could give you a bad result too. That’s just reality with surgery, and not just hernia surgery. To tilt the probabilities a bit more in your favor, pick one of the best surgeons, but you still have to pray hard even then.

[Good intentions]

The best thing that you could do for your decision-making problem is to learn about “odds”. You used the word but you don’t seem to really understand what it means. All of your questions and comments assume that certainty is possible. It isn’t. Learn about probability and maximize the odds for you by choosing the method and surgeon that give you the best probability of a good result.

I don’t know if you are just carrying on the facade or have forgotten but Chuck met your criteria, below, and ended up in a similar situation to yours. He took a referral, let the surgeon do his thing, and had terrible results.

As for why Dr. Harris recommended open mesh, it’s probably because the person he was talking to had had mesh removed that had been placed laparoscopically. Lap mesh had already failed, as far as Quality of Life was concerned. Open mesh, to his thinking, might give better results.

” I think in life it’s best to be a dumb ass. Got to your primary care go where he says get mesh slapped in open and go back to life.”

[David M]

Gi, when Meshornot mentions “best odds”, I do think he’s thinkng about something other than certainty. And he is right that it is hard to really filter for the best odds. In the first place, the general data is only vaguely trustworthy and the specific data for individual surgeons is mostly unavailable. Even Watchful’s recommendation for Conze is somewhat hard to trust, because there is probably no data available specifically for him. He can tailor, which is a plus, but are his outcomes for the different approaches better?

Listening to Dr Towfigh’s latest talk with the lady doing research, they certainly recognize that the hernia research as a whole could be better. And to top that insufficiency of research, I think her guest said that the lag between research and an implementation of that research in practice is as much as 17 years. I think we’ve kind of come to that conclusion for all but the most specialized hernia surgeons. Even most of them are set in their approaches, which makes sense given the need to be conservative with surgery. Her guest also said something about there possibly being a 30% chance of chronic pain with hernia surgery, though that was probably for all hernia types.

So, even though it’s less of a mess than it was 100 years ago, it still seems like there is a lot of room for improvement.

[Good intentions]

Well, actually, my point about understanding probability was more about Chuck, Meshornot, DConfued77, and JHawley’s constantly reducing the odds down to one or two anecdotes about a problem with a certain surgeon or certain type of repair. Fro example, to these guy(s) one in one million is the same as one in one hundred. A single problem is used to define everything. The ironic result of that logic pattern is that it suggests that they should find a surgeon who has done the fewest repair procedures. Just make sure that they haven’t had a problem yet. They will be “perfect”.

But, to the same point and related to your comment about Dr. Telem, Dr. Towfigh’s interview subject, here is a recent paper of which she was a co-author. Interestingly enough, it suggests that an open repair (I assume that means open with mesh although it’s not defined in the abstract) has better odds of not having a recurrence. Or, in their words, lower risk of having a recurrence.

It’s pretty fascinating overall, even though they threw in the typical caution that the results might be due to some extraneous factor. “Surgeon volume”. The study showed that open repair gives better results than MIS. Bucking the trend.

https://link.springer.com/article/10.1007/s00464-022-09586-z

2022 SAGES Oral
Published: 20 September 2022
Five year trends in surgical technique and outcomes of groin hernia repair in the United States
Anne P. Ehlers, Yen-Ling Lai, Hsou Mei Hu, Ryan Howard, Giana H. Davidson, Jennifer F. Waljee, Justin B. Dimick & Dana A. Telem
Surgical Endoscopy volume 37, pages4818–4823 (2023)

Abstract
Introduction
Despite being one of the most commonly performed operations in the US, there is a paucity of data on practice patterns and resultant long-term outcomes of groin hernia repair. In this context, we performed a contemporary assessment of operative approach with 5 year follow-up to inform care for the 800000 persons undergoing groin hernia repair annually.

…

Results
…
Patients in the open cohort had a lower incidence of operative recurrence at 1-year (1.0 vs 1.5%, p < 0.001), 3-years, (2.5 vs 3.5%, p < 0.001), and 5-years (3.7 vs 4.7%, p < 0.001). In the Cox proportional hazards model, we found that patients who underwent an open groin hernia repair were significantly less likely to experience operative recurrence (HR 0.86, 95% CI 0.79–0.93).

…

Conclusions
In this study, we found that open groin hernia repair was associated with a lower risk of operative recurrence over time. While this may be related to patient comorbidity and age at the index operation, future work should focus on the impact of surgeon volume on outcomes in the modern era.
“

[MarkT]

A couple of points from that study:

“Perhaps the most important finding from our study is that the risk of operative recurrence following elective groin hernia repair among older adults is very low, and that the difference in recurrence rate between approaches was small.”

In terms of their findings of less recurrence for open vs. minimally invasive repairs, it is important to consider their potential explanations.

The note that the patients who underwent open repairs tended to be older and less healthy than those who had minimally invasive repairs, and thus may have been less suitable for recurrence repairs. They cite some evidence that claims data can underestimate actual recurrences by up to 40%, and it’s possible that they is particularly true for the older, less healthy patients than for younger, healthier patients.

The reason the authors suggest that surgeon volume also needs exploring (something their Medicare data did not capture) stems in part from a Veteran’s Affairs study from 2004 they cited that compared lap and open repairs and found it to be relevant.

The VA study showed an interaction effect between surgeon experience and recurrence, in that the risk of recurrence depended upon surgeon experience for lap repairs, but not for open repairs.

With lap repairs, recurrence risk was nearly twice as high among inexperienced surgeons (defined as having done less than 250 lifetime repairs) compared to experienced surgeons…further, the lower recurrence risk of experienced lap surgeons was on par with the lower risk for all open surgeons.

What that means is that you could have an overall result that suggests there is lower risk of recurrence with open repairs vs. lap mesh repairs, but when you account for surgeon experience, you realize that the problem is not the repair, it is the experience of the surgeon, because the poorer results among inexperienced lap mesh surgeons are dragging down the overall outcomes, as experienced lap mesh surgeons achieve the same outcomes as the open surgeons. The repairs are actually ‘equally good’…you just need experienced surgeons doing lap mesh.

Does this sound familiar? Yes…because many strongly suspect the same is true for other repairs, like Shoudice!

The authors also cite a 2019 study that found more than 75% of surgeons who offer lap mesh repairs do them for less than 20% of their patients, so it might take them a long time for them to reach a high level of proficiency with it, even though they are otherwise an ‘experienced’ surgeon.

If this is accurate, it would speaks to the general advice several of us repeat around here that it is wise to find not only an experienced surgeon, but a surgeon who is experienced *with the particular repair you will be getting* as there is evidence to suggest this matters (at least for some repair types).

Side note: the VA study used a threshold of 250 lifetime repairs to differentiate between low and high experience surgeons. Now I don’t know why or how they arrived at that particular threshold, but some of you might remember me wanting more info about the surgeons in the study that Chuck (or one of his aliases) keeps posting that found abnormally high complication rates for Shouldice (and another repair) compared to what high-volume specialists report. Specifically, my concern was that the three surgeons were simply characterized as ‘experienced’ with both tissue and mesh repairs…but taking a closer look, that was on basis of them having done > 100 of them. Is that ‘experienced enough’? The VA study would suggest not, at least not for lap mesh. I *strongly* suspect the same is true with Shoudice, which is not an ‘easy’ repair by any stretch.

(as a note, I didn’t pull the VA study or the other cited study, so I’m taking what the authors of this study drew from them at face value – it would be worth reading them too because you never know…).

It hopefully becomes apparent why we can’t just rely upon the info contained in abstracts and summaries, and why one study’ methods and findings need to be taken in the context of the body of work that is out there.

[David M]

I appreciate both of those posts – the one from GI with the study link and the one from MarkT explaining the study. I was confused as to why skewing older might have caused the open group to have fewer recurrence surgeries. It seemed counterintuitive. The explanation that the older population just might not have been good candidates for recurrence surgery sort of makes sense, though the age difference didn’t seem quite as high proportionally as the recurrence difference.

The experience factor for becoming proficient for each of the types sounds believable.

As far as Shouldice, I don’t remember hearing a threshold for experience like the 250 number we hear from lap, but it seems reasonable that there is a significant one.

[MarkT]

It is worth noting that the 250 figure for lap is a methodological convenience in this study…it is not established as some automatic and accurate threshold for what constitutes more or less experienced (never mind as a perfect proxy for more or less proficient).

Also, the age/health differences are offered as one potential (and partial) explanation for the differences observed in recurrence claims, so it would not be expected to fully explain the gap. They also talk about surgeon experience and some other factors.

We don’t have a firm threshold for experience or proficiency with Shouldice, but we do know that it is a relatively difficult and complex repair, so the number is not likely to be low…and the training model briefly outlined on the Shouldice Hospital website gives us some indication of how that institution addresses the question:

“All staff surgeons, regardless of their prior experience, are required to complete an extensive introductory training period, during which time they learn our specialized repair technique that requires the use of mesh in less than 2% of all cases. First, they must assist a Shouldice surgical team for at least 50 operations before they are permitted to perform the Shouldice Repair. As this gold-standard technique can take even an experienced surgeon several months to master, each of our surgeons must further complete up to 100 supervised operations under the watchful eye of a senior staff surgeon before being approved as the leader of a surgical team.”

Presumably much of this is based upon their experience training their surgeons in their repair. They feel that assisting on ‘at least 50’ is required to become experienced or proficient enough before they perform their own repairs. Then they not only acknowledge what they feel is enough to lead their own team, but also acknowledge the variation at the individual surgeon level for developing sufficient proficiency to lead a team, by stating that they need to do ‘up to 100 more’ under direct supervision.

Going further, they also have senior surgeons available for consult before and during repairs, and sometimes they will come in and assist, or even take over, from a more junior surgeon, if need be. I understand they also tend to allocate more complex cases and recurrences to more senior staff, which is an explicit acknowledgement that the learning curve still continues on.

I’m using that institution as an example simply because the info is accessible. I’m sure (well, I hope!) various speciality clinics have their own system, but it does make you wonder how other surgeons are trained, and by whom, and how many ‘reps’ they have under their belt before they are offering repairs unsupervised to patients.

[William Bryant]

Choosing an experienced surgeon, regardless of whichever repair is favoured, is what most people recommend. But surely this will, to a great degree, be negated by a “tailored” repair as most surgeons will not be particularly adept at their fall back option. A surgeon who specialises in tissue may be inexperienced with mesh by comparison. Is that the case?

Possibly Dr Kang is one of the few who has done a fair number of both tissue and mesh repairs. Have other surgeons performed both a high volume of mesh and tissue repairs?

[Watchful]

David M – that was exactly the case with my dad. He recurred many years after surgery (Marcy-like for an indirect hernia), and he was too old and with too many other medical issues to consider another repair when that happened. His hernia is awful, but he has had to live with it.

William – there are a few surgeons who are very experienced with both – German surgeons who have been mentioned here. They do about half mesh, half tissue.

[Good intentions]

Thanks Mark T. Overall though, from a probability perspective, the work still shows that a typical patient can expect a lower risk of recurrence if they choose a surgeon who does open repairs. Because, realistically, nobody has any way to tell if a surgeon has become proficient in the method that they are using. No surgeon tracks their patients welfare to a degree that shows them when their skill level has been maximized.

Another way to look at it is to see that open repairs are “easier” to learn. The odds of any surgeon being good at open are better than them being good at lap.

Who wants to be the training subject for those surgeons that don’t have their 250 procedures done yet? Besides the fact that there will obviously be no magical break point at 250. And, I’ve never seen anybody describe how these surgeons are allowed to “learn” independently. How is it okay to know that new surgeons are unskilled but still allow them to practice on their first unsuspecting patients. What happened to professional ethics? The Hippocratic oath, etc. If the data consistently shows that rookie surgeons cause more harm then they should have an experienced surgeon assisting them until they reach a certain level. This is another case where I actually feel bad for the surgeons. Thrown in to practice to immediately start giving patients sub-standard care. It really is, by definition, sub-standard. The studies show it. In effect, it’s a competition among patients to let somebody else suffer the 250 training procedures.

And, extending the risk analysis process out even farther, if you consider the use of general anesthesia, then choosing an open repair method makes sense.

Was there any mention of chronic pain in the full paper? The number one problem in mesh-based hernia repairs? How could they overlook that factor? It was well-known at the beginning of the study.

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