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March 8, 2012

BehindTheMedspeak: The dirty little secret of hernia repair surgeons don't want you to know

Anesthesiologists who care for patients undergoing hernia repair have known for decades that laparoscopic techniques are inferior to the old-fashioned open approach (above) in several respects.

The Wall Street Journal's Laura Landro brought this news to the great world in a February 28 article, from which excerpts follow.

Hernia repair, one of the most common surgical procedures, carries a risk many patients don't consider: chronic pain after surgery.

More than 30% of patients may suffer from long-term chronic pain and restricted movement after surgery to fix a hernia, a bulge of the intestine or body fat through a weak area in the abdomen, studies show. New synthetic mesh devices, though better than traditional sutures at reinforcing the abdominal wall, can irritate nerves and carry a slightly higher risk of infection.

More than a million patients a year undergo surgery for some kind of hernia. About 80% are so-called inguinal hernias in the groin area. There isn't always an obvious cause. Some are hereditary or linked to weakness in the abdominal wall that may happen at birth when the abdomen lining doesn't close properly. Hernias can affect both adults and children, and men are most at risk.

There are two main approaches to repairing a hernia: an open repair that requires a large incision, or a minimally invasive laparoscopic technique, which uses a camera to guide instruments through a tiny incision.

Studies show that patients undergoing minimally invasive surgery have a quicker recovery and less short-term pain than with open repair. But in either surgery, small nerves can be irritated by the procedure or the repair mesh as well as by sutures or tacks used to hold the mesh against the abdominal wall.

Serious complications can occur if the surgical mesh or other devices break or become twisted or dislodged; a commonly used mesh product was recalled in 2006 by its manufacturer because of the potential for breakage inside patients, and a number of class-action suits have been brought by patients who experienced complications like bowel perforation and infection.

Not only do modern laparoscopic techniques take longer than open repairs — oftimes three or four times longer — but they also always employ placement of surgical mesh over the defect.

Thus, a foreign body — with its accompanying risks of infection and post-operative discomfort and/or pain due to mechanical factors, in addition to the possibility of an inflammatory reaction to the mesh — is part and parcel of the procedure, which requires inflation of the abdomen with carbon dioxide under pressure to enable the surgeon to visualize the herniated intestine.

An open repair by an experienced surgeon — something that will grow increasingly uncommon as older surgeons who trained doing open repairs give way over time to younger surgeons for whom the default procedure is laparascopic — is very quick, on the order of 15-30 minutes, without the need for placement of mesh.

In addition, complications are much less likely to occur because the approach under direct vision is unambiguous and relatively uncomplicated, as opposed to the limited field of view and restricted access via the laparoscope.

I have watched laparoscopic surgeons struggle with closing hernia defects and mesh placement for many more frustrated hours than I care to recall, and one of the things that has most impressed me is how arbitrary the technique is, as opposed to open visualization and closure of the hernia.

One other thing: a competent surgeon can perform an open repair using local anesthesia with conscious sedation; laparascopy requires general anesthesia including endotracheal intubation, total muscle paralysis, and machine ventilation.

I'll opt for an open repair — hold the mesh — 100% of the time, if it's my hernia.

March 8, 2012 at 02:01 PM | Permalink


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Ultimately, informed consent is neither. Even physicians are at a disadvantage where the proposed procedure lies outside their field of practice.

How can a patient of average intelligence and average education even begin to grasp the scope of the procedure / Tx plan absent extensive medical training? Where do patients with major affective disorders, closed head injuries, and dull-normal intellect (got that comma) fall in the continuum of "informed" as consent is granted?

I'm for OR TV, 24/7 surgical coverage - every where and every time. Imagine watching the greatest hits of the chest-cutter you might engage for your CABG? That's "informed" in a manner not contemplated by today's standards.

Posted by: 6.02*10^23 | Mar 9, 2012 10:52:58 AM

Your story is misleading. The risks, benefits and alternatives to surgery are discussed with patients prior to any operation. The current standard of care for open hernia repair, the Lichtenstein or tension-free repair utilizes mesh, either biologic, polyethylene, PDFE, or a combination. Mesh repairs have a much lower recurrence rates than do tissue repairs, where the defect is merely sutured closed. The purpose of the mesh is not to hold in the herniated organs but to serve as an inflammatory substance that will promote the. Formation of a robust scar that will prevent future herniations. Laparoscopic repairs can be good choices for recurrent hernias where the normal anatomy has alreaded been disrupted, patients who need bilateral repairs, or where incarcerated hernias exist and conversion to open laparotomy to examine bowel may be required.
Despite advancements in surgical technique, sterilization, and preeoperative antibiotics, surgical site and hardware infections continue to complicate surgeries. It is up to each patient to weigh the risks and benefits and decide whether or not they want surgery.

Posted by: Ben Franklin | Mar 9, 2012 2:31:28 AM

Since my mother nearly died from an infection due to her hip replacement (hardware and cement came loose, giving plenty of room for infection), I've been following hip replacement replacements. People just don't know what they're getting into when they have one at 50. By the time they're 65, the replacement will be worn out and revision surgery can easily leave them with one leg much shorter than the other. That's if the replacement can be done at all.

Caveat emptor.

Posted by: Becs | Mar 8, 2012 4:52:23 PM

Good to know. Thanks for sharing that info.

Posted by: HeavyG | Mar 8, 2012 2:15:51 PM

An open repair requires fewer tools and gives the physician the added advantage of seeing much more of their patient possibly finding incipient pathologies that would otherwise go undetected. I'll take the open procedure, please.

Posted by: 6.02*10^23 | Mar 8, 2012 2:15:28 PM

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