Surgeons with hernias – what would they do?

[Good intentions]

The two most interesting things to me are – One, that they would wait even though almost any surgeon you talk to about a hernia today will imply that if you wait you could end up in the emergency room or dead, due to incarceration of the hernia. So, if the results represent the views of the surgical community, then surgeons are giving advice to their patients that they would not follow themselves.

And two, that so many surgeons choose laparoscopic methods even though there is little data to support long-term results. They have been convinced, but for unknown reasons. I did just find one paper from 2019 in which patients were identified from the Danish Inguinal Hernia Database and asked to participate in a study. The authors conclude that 13% of people who have bilateral TAPP mesh placement suffer from chronic pain.

So, the information is out there, if the professionals want to find it. I wonder what the people in the Twitter survey would answer if they had read of these results beforehand.

It is a fascinating real-time story. Like living in a documentary.

“Decreased functional performance” = debilitating.

https://journals.sagepub.com/doi/10.1177/1457496919874483

Excerpt –

“Conclusion:
Bilateral transabdominal preperitoneal inguinal hernia repair for symptomatic inguinal hernias was related to a high incidence (13%) of chronic postoperative inguinal pain and decreased functional performance status.”

[Watchful]

Good Intentions… There are two possibilities. One is that the surgeons in this survey wouldn’t agree with your statement that “the numbers about mesh implantation say that a pure tissue repair is the safest for long-term welfare.” The other possibility is that they think the skill of the surgeon overrides that.

The most interesting part of that survey was that more than half (56%) were in favor of avoiding surgery until symptoms progressed beyond minimal. The problem is that it’s not clear what minimal vs non-minimal means exactly, and it may mean different things to different surgeons.

[William Bryant]

The question avoid surgeons or fix me is a bit simplistic, bit loaded. Even then most avoid. If it were try to fix me, attempt to fix me the difference may be more.

Then again I suppose avoid surgeons accept risks would be too.

[William Bryant]

Again, how many are fully aware of tissue repairs? It’s largely a lost skill so unless they’ve come across it, would they actually all know about it?

I’m not the most erudite on this forum or the intellectual but the lost, forgotten skill thing is a bit like asking if you were to do clothes washing would you use a washing machine or hand wash?

Most people would use machine (convenient, easier, what they know, deemed to be mote current) despite risks of shrinkage, damage etc.

Tissue repair is so distant to many it isn’t even taught. So how would many surgeons know much about it?

To make an informed decision it would have to be ascertained that all respondents were aware equally of all methods and all risks.

Ps. As it’s 5am I haven’t read all links so don’t know if they were or not!

[Good intentions]

I was able to find this old post after searching for it because of the recent posts about most surgeons choosing mesh. Apparently they do, after avoiding surgery completely.

I just can’t understand the logic of the thought process. The numbers about mesh implantation say that a pure tissue repair is the safest for long-term welfare. But, apparently, get mesh is what the professionals think. They will take that one in six chance of chronic pain. Of course, it’s all that they’ve been trained to know.

They will put their trust in the surgeon, but, as the survey shows, the majority of surgeons will choose mesh. It’s an odd circular argument, self-reinforcing. I wonder if there is some “taking one for the team” psychology going on.

https://twitter.com/Herniadoc/status/1114246402950012930

Fascinating audience polling by @DrMicki of laparoscopic general / hernia surgeons. Here are 3 questions:

Q1: how many of you would have your minimally symptomatic inguinal hernia repaired?
A: 56% choose watchful waiting. pic.twitter.com/oZ0RCpcknH

— Dr. Shirin Towfigh (@Herniadoc) April 5, 2019

[kaspa]

I wish you good luck. I think you did a right decision. Don’t worry, they’ll do the same repair they would 10 years ago.

[Dill]

As someone who has done watchful waiting with an asymptomatic smaller reducible hernia for 10 years, and who is going to have it surgically fixed tomorrow, I was supported by my GP and a surgeon in watchful waiting. It has grown in size this year and is starting to give me pain–I think I maybe could have done more exercises, used a truss, but the thing is now it is something that I need to attend to daily. My GP said “it’s probably time to get that fixed.” I trusted that more having been told it was fine to wait. I don’t think I’m in danger now but I worry. I think some of the answers of the surgeons might be that they work with anesthesiologists and maybe have more confidence in that. To me, one of the big benefits of open is no general anesthetic. So even though my hernia is larger now, I still would have waited. If I do have pain after the surgery, well that’s ten years less of pain. So I’m really glad the original surgeon offered waiting as an option.

[Tino_7]

quote drtowfigh:

Interesting answers, right?

The data shows risk of watchful waiting to be 0.18%/yr and most of us (should) include that as part of our consent to the patient. Or, it’s safe to wait.

We also know that that the risk of complications, including chronic pain is lowest with laparoscopic repair with mesh done by an expert surgeon. That includes comparators of open with mesh and without mesh.

We also know that surgeon skill is directly related to outcome, including recurrence and chronic pain.

Really appreciate your input on this forum, Dr. Towfigh. You’re unquestionably a leading expert in this area.

The risk of post-op urinary complications (need for Foley catheter) is higher for lap repair because the patient undergoes general anesthesia vs. twilight. What do you suggest for men with very large prostates (150 grams or more) with a history of difficult urination (needing alpha blockers + Finasteride)?

Open mesh and open non-mesh under twilight + local reduce risk of needing a catheter, right? (Forgive a layman trying to understand medical journals.)

I’ve been doing watchful waiting, but my hernia is bothering me more, and so I want to consult with a doctor who does Shouldice or DeSarda (sp?). I know of someone who saw Dr. Tomas and had great results.

I am much closer to Dr. David Grischkan than I am to you or Dr. Tomas, and travel costs are an issue for me.

I need prostate surgery too and just don’t know if I can put off hernia long enough to get prostate surgery and recover from that. But your statistic above is informative in my decision making.

If I lived near LA, I’d have already scheduled a consult with you by now.

thank you.

[Hiway40blues]

After reading this, I’m wondering where does this leave us? If many surgeons would defer IH surgery themselves, for fear of complications, shouldn’t their patients do the same thing? I have had one IH repair (right side) done, and I’m pretty satisfied with it. Now I have to consider a left-side repair. I do not want to go through that again. On the other hand, I would like to get back to a normal life, without thinking about this subject every day. But surgeons (including mine) know more than we can about IH surgery-and the majority of them would wait (!) This information is upsetting-it makes it much harder for us to make a decision.

[drtowfigh]

Contents do not determine whether a hernia should be repaired.

[UhOh!]

quote Good intentions:

Yes, it doesn’t seem to fit what most surgeons tell their patients. Very few seem to recommend waiting. The message the patients receive is that bad things can happen, emergency rooms and death, so you should get it fixed soon.

Perhaps this is an argument for making diagnostic imaging part of standard practice. Those risks exist, but, as I understand it, the likelihood of them coming to fruition varies greatly depending on hernia type and contents… which can certainly influence the decision about surgery… which one can only know with imaging…

It’s why I asked for imaging to be done of mine. US revealed fat-only, which is a big part of what made me comfortable to just wait and let symptoms guide decisions.

[kaspa]

Nice topic here. Of course, Dr Towfigh must be right as an inside trader and surgeon’s wouldn’t rush for a repair. But when they do, I think they’ll use same surgery they do. If they do a mesh, they’ll prefer so. If they’re non-mesh, they’ll prefer tissue repair.

But there must be lots of variation here. If I was a surgeon who does mesh repair because that’s what they taught me and anyone thinking otherwise is crazy inside institution, anyway I think I’d take a non-mesh repair elsewhere…

[scaredtodeath]

Great question

[pinto]

“Indication for hernia repair is not based on size, but primarily based on symptoms.”
Surely, but only if the surgeon does mesh repair. If suture repair, then wouldn’t the factor of size loom large?

[drtowfigh]

The evidence is for asymptomatic or minimally symptomatic inguinal hernias. It is strong in showing that watchful waiting is safe.

Indication for hernia repair is not based on size, but primarily based on symptoms.

I recommend that that if a hernia is getting larger, then one should consider repair, as it’s an easier operation with better outcomes. But that doesn’t mean I’m saving a life by recommending that. It’s a discussion to have with the patient and their needs.

[ajm222]

quote drtowfigh:

If surgeons are promoting early or urgent elective inguinal hernia repairs, that’s not supported by level 1 evidence.

What about the notion that the longer you wait, the larger the hernia will become over time, which could increase the chances of complications or recurrences after repair?

[pinto]

All of that quite true I am sure but subtle social reinforcers could have been present. The “conference” has been a subject of sociological study and hardly absent social factors or elements. Even within the sparse commentary available by the lap conference attendees, one can readily see their thinking influenced socially by their medical collective or association. That’s natural of course, for as much as a medical society is medical, it is social at the same time!

[drtowfigh]

They weren’t in close proximity. And most chose watchful waiting. Laparoscopic repair with mesh was choice of operative option. And they felt choice of surgeon was more important than choice of technique.

[pinto]

Perhaps but the respondents were presumably in close proximity even sitting next to each other. Then again they also may have assumed a higher chance of incarceration, encouraging them to favor early surgery. They are also likely to be enthusiastic about lap by virtue of their conference attendance, so their choice of personally getting lap isn’t surprising. In this regard it doesn’t necessarily show lap superiority if some readers might conclude so. Polling/surveying isn’t always what it appears.

[drtowfigh]

Method: Audience survey via text-in polling. So basically anonymous.