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.

Does OR staff hair cause infections?

“Zlatan” (not his real name) writes:

I just recently found your blog and read about shaving patients and agree with all that you said. My question is about the staff's hair. Sorry if you have addressed this, I couldn't find it. 

I work at a VA hospital in surgery. I have been in the OR environment for 30 years and have seen quite a lot and been through many inspections. We had an independent nurse evaluate us for upcoming JCAHO inspection. We 'failed' due to not covering facial hair and chest hair with scrub attire and in addition were told folks with hairy arms needed long-sleeve scrub tops. Of course this comes from the all powerful AORN. Being an evidence-based person at heart, I began to look for some evidence regarding covering up (that is how I stumbled onto your blog). Do you have any knowledge of evidence based practice regarding hair covering and infection rates? I appreciate your time.

Thanks!

Great question. Where do they come up with these things? Chest hair? Arm hair? Long-sleeve scrub tops?

For the record, I am against wound infections. I would do anything reasonable to try to prevent them.

I suspect your independent nurse evaluator may have over-interpreted the rules. My distaste for the Joint Commission (by the way, it’s no longer called “JCAHO”) runs deep, but I don’t think even they have thought of those wrinkles to the hair issue.

It is possible though as the JC and the AORN seemed to be obsessed with hair.

How does one define "hairy arms"? I assume long sleeve scrub tops would be for the circulating nurse only. If the surgeon and the scrub tech wore long sleeves, they wouldn’t be able to properly wash their hands and arms.

Regarding the chest hair, are we talking male or female staff? (Just kidding.)

As far as I know, there is not one shred of evidence linking shed skin or hair on the head, face, chest or arms of OR staff to patient infections. This is after an exhaustive search of PubMed, CDC, and holding nothing back, I even crowd-sourced the question on Twitter.

In case some readers missed my post on the ritual of clipping the hair of patients before surgery, the link is here. The post was about rules that people make up without any justification to drive us all crazy.

I collected several such rules related to presumed infection prevention in the comments section of that post and elsewhere. Here they are.

No forced-air warming until patient is draped.
No briefcases in the OR.
No one may enter the room without the circulator's permission.
No room warming as it may cause condensation on surgical instruments. (Children and burn victims who may become hypothermic be damned!)

Remove masks every time you leave the OR. And no letting them hang down with just the lower tie done.

Masks must be worn by anyone in the scrub sink area even if that person is not scrubbing but just walking by.

All OR personnel must wear long sleeves because of the potential for "shedding skin."

But the independent nurse reviewer has spoken. I’m betting that long sleeve scrub tops and chest and arm hair police will soon appear in your OR.

Who should place a Foley catheter?

A nurse who understandably asks to remain anonymous writes, “In our hospital, we have an increased catheter-associated urinary tract infection (CAUTI) rate related to poor skills by medical residents. The surgical nurses want to insert the caths, but the residents jump in and do not perform the skill correctly. Feedback please.”

Thanks for the interesting query. Several thoughts come to mind. I can understand a new resident wanting to learn how to perform this procedure. But after doing a few, I think that the novelty would wear off, especially at 3:00 in the morning. Also, it is likely that the nurses would be able to do it in a much more timely way.

In my current hospital, which is non-teaching, nurses place Foley catheters without incident or opposition. I don’t know our rate of CAUTI, but I doubt it is high.

You might try the direct approach and speak to the residents when they don't do it right, but unless they've read my "Hints for new residents" blog where I mention that you can learn a lot from nurses, they may become indignant.

I assume you have some data to back up your assertions that your CAUTI rate is high and can document that the residents are not doing it correctly. Having dealt with teaching hospital politics for many years, I suggest the following to you.

Speak with your nurse manager and the nurse who does clinical education and tell them what the specific problems are. For example, are the residents not adhering to sterile technique? Are they not following the steps properly?

The nurse manager and clinical specialist should talk to your infection control nurses and their supervising physician, who should then discuss the matter with the residency program director. This will keep you out of the line of fire and not jeopardize your relationship with the residents.

This process is good way to handle any sort of conflict. In the military, it is known as following the chain of command.