Wednesday, October 2, 2013

Umbilical hernia repair: Choosing a surgeon and more



A reader writes (in italics). My comments are in normal text.
 
I am writing on behalf of an otherwise healthy 30-ish-year-old relative, who was recently diagnosed with an umbilical hernia, and another “just above it”.

She was diagnosed about a month ago, and was sent to see a surgeon (not sure what kind). The surgeon suggested a repair using mesh. She’s apprehensive moving forward with surgery based upon several reasons:

She felt rushed during the consultation. She wasn’t given much information regarding the procedure, wasn’t prepared with many questions, and failed to voice her questions/concerns. She has since tried to contact the office to get some questions answered but hasn’t gotten a response.

This is not medical advice. For that, I would need to examine your sister.

It was probably a general surgeon. You have mentioned three red flags—she felt rushed, she wasn't given much information, and the office has not called her back. I would suggest you get another surgeon.

She consulted Google and has read “bad things” online. She is concerned with the probability of having to have repeat surgeries.

Recurrence may occur after any hernia operation. For a small umbilical hernia, the risk should not exceed 5%. The infection rate for umbilical hernia repair is also fairly low, but if an infection occurs, a recurrence is likely.

Can you offer real information regarding the types of procedures out there? Are there superior methods, as suggested by many of the “scholarly” looking articles, which eventually turn into advertisements? Many tout methods such as Shouldice, Bassini/McVay, Tension-Free, etc. The info I have come across is conflicting and confusing.

The information on the Internet is confusing. The methods you mentioned are eponyms for groin hernia operations. They do not pertain to umbilical hernia repairs. There are three currently accepted methods of repairing an umbilical hernia—open suture repair, open mesh repair, and laparoscopic mesh repair. The mesh repairs involve insertion of a piece of artificial material to reinforce the abdominal wall. The theory is that the patient's tissue broke down once so why rely on it to fix the hernia? Recurrence rates (at least rates that are published) tend to be significantly lower when mesh is used.

I am unaware if there is a hernia sub-specialty, but if there is, what would be the best way to find such a surgeon? If not, is there an existing database that provides information that details the number of hernia surgeries performed by a surgeon?

There are some surgeons who specialize in repairing hernias. I don't know of a database listing the number of hernia operations performed by individual surgeons, nor is there any information on individual surgeons' recurrence rates. The latter information is usually unknown even to the surgeon because patients with recurrences tend to go elsewhere for repeat surgery.

Can you list questions she should ask her surgeon that will aid her confidence in the decision-making process? Her pain symptoms started about 2 years ago, and I fear what she risks by continuing to delay.

Questions that should be asked include the following: what type of repair should I have, how many of these repairs have you done, do you know your recurrence rate, what if I need to contact you at night or on a weekend.

Because she is symptomatic, she probably should have elective surgery. Not having surgery runs the risk of incarceration, or the trapping of a piece of intestine in the hernia. If this happens, pain would be severe and the hernia would not be reducible. Emergency surgery would be required and the risk of recurrence would be higher. If the bowel's blood supply is irreversibly damaged, some of it may need to be removed. This also increases the risk of complications.

I would find another surgeon to do the operation, preferably a general surgeon with expertise in hernia repairs. If the two hernias are not close together, the laparoscopic method might be best provided she has not had extensive prior abdominal surgery.

I hope this helps.

4 comments:

  1. I agree with the advice above. You should be comfortable with your surgeon and have a chance to ask all your questions. Many general surgeons fix hernias, and it is controversial in the field whether or not hernia surgery should be considered a specialty, or whether outcomes are better at hernia centers. That behind said, surgeons who do a lot of one thing and who stay on top of the latest research and newest technology will tend to do better. You should also ask how often they do this operation and about the data that supports their recommendation for one approach vs. another (mesh vs. no mesh, lap vs. open, type of mesh used). Also, hernias are rarely emergent, so feel free to get a second opinion. The American Hernia Society website is a good resource to find a surgeon that is dedicated to hernia repair.

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  2. Andrew, thanks for commenting. I appreciate the mention of the American Hernia Society.

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  3. Might be worth a comment about anesthesia - local often for mesh vs general for lap.

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    1. Good point. I should have mentioned that.

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