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.

A UK Med Student Discovers Surgery, Has Questions

Gareth (not his real name) writes

I came across your blog a few days ago and I have been reading it since. I am a third year medical student studying in the UK. I am writing to you because I would be grateful if I could get some advice. I have always wanted to become a doctor, since I was veryyyyy young, but I never ever considered a career in surgery. Before medical school, I believed that surgeons were like butchers, not capable of any human attachment for the patient etc etc. I believed I would not be able to bear the responsibility to cut someone open given the fact that I am a very emotional person. However, my perspective changed when I was in the OR and saw my first surgery. It was a coronary bypass surgery and I loved it, I loved the idea of making the patient better in such short time and the fact that the surgeon was the one responsible for it, I suppose it must be very satisfying. Therefore, I have started to consider a career in surgery, however, I am still very unsure of whether I have the right personality type and skills to become a surgeon. I still tend to get very attached and moved by patients' stories and experiences and I don't know whether that would help me detach myself from the patient whilst operating. Also, most surgeons seem to be extremely confident and outgoing whereas I tend to be shy and not confident, even though I'm quite good academically. So I am really confused right now. Also, I have never had great hand skills, even though I took some introductory surgical skills courses and they went quite well. I seem to get a bit of tremor when I do practical stuff though, I guess that's because I get nervous. 

I'd like to ask you one more thing. If I do decide to go for a career in surgery, is there any point for me to try and take the USMLE and apply for a US residency after graduation? I heard surgery it's really competitive, I guess many schools don't even accept international applicants?

Thank you very much for your time and dedication. I admire the passion that you show.

Thank you for reading my blog and for writing. I am glad that you have realized what a rewarding career surgery can be.

First let's talk about the "surgical personality." There was a time when most surgeons could have been categorized into a couple of personality types. Those days are gone. Now that 40% of all surgical residents are women it is no longer necessary to be a certain type of individual. I know many surgeons who are quiet, thoughtful and introspective. You need to dismiss any thoughts about your personality type being incompatible with a career in surgery. Also it is not a bad thing for a surgeon to identify with and become attached to his patients.

The next myth is that one must have great dexterity to become a surgeon. In the old days some residency programs use to screen applicants by making them build model airplanes. I don't believe anyone still does that. Now it seems that video game skills are much more important since so many procedures are done laparoscopically. I believe that anyone can become a more than decent technical surgeon through practice. We all get nervous. This is a real person you are operating on. I have written that there is more to surgery than manual skills. It is very important to know who to operate on and when to operate on them as well as who not to operate on.

I have written before about the decreasing chances of graduates from non-US medical schools obtaining residencies in the United States. US medical schools are expanding their class sizes and a new schools are opening. It is not even clear that all us graduates will be able to obtain residency positions in the future. The most recent statistics from the match show that only about 5% of non-US citizen graduates of foreign schools matched into categorical general surgery positions. However, I do not believe you have anything to lose by trying. You will need to get an excellent score on the USMLE and of course, have good grades and recommendations. Although it is difficult, some trainees from the UK have been able to find fellowships in the US. I do not know how easy that will be in the next few years.

Good luck

A pre-med student asks some probing questions

Here are some questions from Lionel, a pre-med student.

What is something you wish you had known before entering medical school?

It would have been nice to have known what changes were going to occur over the 40+ years since I graduated.

If you had the opportunity to choose a specialty all over again, would you do surgery again?

Yes. While I have often envied the controlled lifestyles and flexibility of radiologists and anesthesiologists, I don't think I could have stood the sitting in the dark all day (radiology) or utter boredom 95% of the time (anesthesia).

If not medicine, what other healthcare occupation would you consider to be more rewarding?

It depends on how you define rewarding. It seems to me that being CEO of a hospital is more rewarding financially these days. I have blogged about that. Is it more satisfying on any other level? I don't think so.

Is it possible to carry a healthy relationship where the significant other is not a medical student? Would it be more/less difficult in residency compared to medical school? [this is one I'm mostly interested in especially since you are a surgeon]

I am living proof that it is possible to have a healthy relationship with someone who is not a med student or physician. I met my wife, who is a nurse, when I was an intern. We were married when I was a third-year resident and still going strong at 39 years.

What implications have enduring medical school/residency had on your personality?

I was always kind of a pessimist, but med school and beyond amplified that trait a lot. As some people have written about lately, med school and residency can induce cynicism, and I'm afraid I am a classic example of that.

Does every single day of the year feel stressful or are there days where you feel in control and free to relax?

Since I retired late last year, the days are not particularly stressful right now. When I was an active surgeon, just about every day was very stressful. It took at least the first five days of every vacation to unwind, longer if I had gone away and left a sick patient to be managed by someone else. Here's a link to a post I wrote about "collateral damage," which is about how complications affect surgeons.

I have always dreamed that being a physician would help me feel more connected spiritually to god/universe by seeing all the unfortunate people and being able to lend compassion. However, does being under constant stress distract a physicians focus from that feeling and does it make you just want to finish the job and go home?

There were many days when I just wanted to finish the job and go home. I would like to think though that I was able to get past that and offer my patients the compassion and support they needed.

What do you like/dislike the most about your journey thus far?

I liked the challenge of figuring out what was wrong with a patient and having the ability to fix it. I liked the feeling of satisfaction after helping someone who was really sick get better. Today I got an email from a former patient who is 10 years postop from breast cancer surgery and disease free. Hearing that is hard to beat.

I took every complication, whether it was my fault or not, very personally. That can wear you down. I didn't like the empty feeling that I got when I operated on a patient and found something like incurable cancer. It was frustrating not to be able to do anything about it. It is very hard to look someone in the eye and tell him that the surgery did not solve the problem.

A patient wants to know when to speak up

Matthew writes:

My only experience with the medical profession is strictly as a patient. I'm wondering what is an appropriate balance between being an educated patient (willing to ask questions, make observations, etc.) versus being one of those supposedly "self-educated" know-it-all patients that I'm sure are one of the banes of a doctor's existence.

We've all heard the stories of the patient whose doctor didn't listen to their concerns until it was too late, but on the other hand, I don't deny that my doctor knows worlds more about my body than I do, or ever will.

I want to trust my doctor, but without having to blindly accept whatever he tells me. Yet I've dealt with members of the medical community who see anything BUT blind acceptance as a personal affront.

As such, is there ever a time to research symptoms online before making an appointment? Is there ever a time to disagree with a diagnosis? Is there ever a time to request or ask about alternate treatments? And if so, how can this be done in a way that is respectful to my physician?

You ask some excellent questions.

I’m not sure I have all the answers. I hope some of my physician colleagues will comment. 

There is a fine and very fuzzy line between asking good questions and being a pain in the ass. And that line is drawn in different places by different doctors. It ranges from zero tolerance for questions (See Dr. Sung on “Monday Mornings,” who, when asked a question about a procedure he recommended, said, “Not do—dead.”) to the most open-minded, usually a primary care doc or psychiatrist. There are issues of time, urgency, the physician’s perception of the patient’s level of understanding, the complexity of the disease or operation and many more.

I had no problem with patients who researched their symptoms online. However, I would hate it when a patient brought a portfolio with 100 pages of downloaded material for me to comment on. There is a lot of garbage on the Internet.

I think you should always ask what your options are. Informed consent discussions should include the risks, benefits and alternatives for any procedure. The doctor should also tell you what the risks and benefits of the alternatives are too.

Go with your gut. If what the doctor says to do does not sound right, say you will think it over. Don’t be afraid to get a second opinion. Run away quickly from any doctor who discourages second opinions. I always encouraged second opinions for patients who were reluctant to have surgery I recommended. I felt that if I was proposing the right thing, the second opinion doctor would support me.

One of the worst things a patient can do is be too acquiescent to the physician. I used to tell patients “Don’t worry about hurting your doctor’s feelings. This is your life we are talking about. The doctor will get over it. If she doesn’t, you don’t want her as a doctor anyway.”