What is Important in Hernia Surgery
(An Experienced Surgeon's Perspective)
Optimal Long Term Results
The way we treat hernias is biased towards what we consider the most important problems in hernia surgery. Basically we take the long view and favor optimizing long term results and safety.
Safety is the number one consideration and it is the reason why it is advisable to repair all hernias in the first place. If it were not for the fact that any hernia can become life threatening we would not be recommending that every hernia get repaired.
Modern anesthesia is very safe with the occurrence of unexpected serious complications in a healthy patient that is much less than 1 in 20,000. Most surgeons will never see this happen. You may learn more about anesthesia from About anesthesia and hernia surgery article.
So what is optimal long term results? It is a low recurrence rate and low incidence of chronic severe pain resulting from the surgery. Everybody talks about having the lowest recurrence rate for hernia surgery. We have seen some hernia centers go so far as to guarantee that their hernia repairs will not recur. Unfortunately we believe that this inordinate emphasis on recurrence rate detracts from the real problem with hernia surgery which is chronic severe pain caused by the surgery itself.
Recent population based European studies have indicated that the incidence of chronic severe pain may be as high as 20% - 30% after hernia surgery. The American literature is nearly devoid of any mention of this problem except for the recent recall of certain hernia mesh products. The techniques used in Europe to repair hernias are identical to the techniques used in the United States. Where the Europeans have us beat is in long term follow up. Their patients tend to live and grow old in the same communities where they were born. This makes it much easier to do long term follow up studies.
In our practice we have seen many patients with chronic pain resulting from previous mesh hernia surgery. We have operated on these patients to remove the mesh to relieve the pain and what we have found is very interesting. In these cases we have found the mesh stimulating the formation of dense scar.
Now the problem with scar is that it contracts and when it contracts it causes pain. Compounding the problem is the fact that when mesh is placed to repair a hernia it is permanent. As long as the mesh stays in the body it can stimulate scar formation. Although they do not openly acknowledge the problem mesh manufacturers are currently experimenting with dissolvable and tissue based mesh for hernia repair.
As for laparoscopic hernia repairs the main problem with this technique is a high recurrence rate. If it were not for the high recurrence rate this could be the dominant technique. Its main appeal is fast recovery but this cannot be important enough to accept a 25% recurrence rate in our opinion.
Our recurrence rate is very good but it is not zero. Our occurrence of chronic pain after hernia surgery though is much better than the recent studies that we cited above. We do most hernia repairs without mesh and we attribute our good results to this technique. We consider surgery resulting in severe chronic pain a failure and any technique that has a recurrence rate of 25% unacceptable and so this is what we consider important.
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