Here’s what you need to know before your next complex hernia repair.
Ventral hernias are common, but when left untreated, they can negatively affect a person’s quality of life by causing pain, impairing function and sometimes creating a disfiguring bulge. When there’s potential for the abdominal contents to become incarcerated or strangulated, a patient may need to undergo emergency surgery.
Those surgeons tasked with abdominal wall repair are petitioning for a shift in how their clinical specialty is perceived. A group of general surgeons, backed by the Americas Hernia Society, recently launched an effort to turn attention away from the disease state of hernias and towards a clinical specialty called Abdominal Core Health.
“This is a huge paradigm shift in terms of the identity of the field and moving towards abdominal core health,” says Dr. Benjamin Poulose, co-founder and director of quality and outcomes, Abdominal Core Health Quality Initiative (ACHQC), chief of general and gastrointestinal surgery, The Ohio State University Wexner Medical Center, past president of the Americas Hernia Society and current member of the AHS Board of Governors.
“We’ve devolved into super-specialty areas, and we need to think more holistically about how to make patients better,” he says. “Hernia just doesn’t describe what I or other surgeons do.”
The ACHQC now has more than 455 participating surgeons in 43 states.
The Challenge of Ventral Hernias
Each year, surgeons perform upwards of 350,000 ventral hernia operations in the U.S. and that number has been rising. Even under optimal conditions, ventral hernias occur in up to 28% of patients undergoing abdominal operations, and more than 2 million laparotomies are performed each year in the U.S. for benign conditions alone.
In addition, between a quarter and a half of all ventral hernia repair (VHR) patients have a recurrence, leaving ample room for improvements that could lower costs and lead to better patient outcomes.
A 2012 study estimated for every 1% reduction in VHR recurrence there would be a cost savings of at least $32 million in procedural costs alone—a cost estimate believed to be low.
Yet federal grant money to study VHR has historically been scarce. The study noted that “Efforts at obtaining federal funding for VHR research are frequently unsuccessful, in part due to misperceptions that VHR is not a clinical challenge and has minimal impact on healthcare resources.”
The authors of the 2012 study, one of the few to estimate the national incidence and cost of hernia surgery, believed $32 million in savings is a conservative estimate, because it does not include physician fees, time patients lose from work, chronic disability associated with hernias or hernia repairs done in federal settings. The authors also predicted an annual increase of 11,000 VHRs in the near future.
Lack of Research
Historically, when it came to funding hernia research, “quite frankly, no one cared,” says Dr. Poulose. “When you ask someone to give funding for research in children’s kidney cancer versus hernia, you can see where the decision is going to go,” he says.
For example, hernias have long been thought of as mostly a male problem, but they’re not, according to Dr. Poulose. He said there are known gender disparities in the field, which need to be studied and addressed.
A Hernia Specialist Shift
Lack of adequate research as well as increasing occurrence and reoccurrence rates have motivated hernia specialists to approach the condition in a new way. As opposed to just being doctors who specialize in hernia repair, surgeons like Dr. Poulose are focused on core strength, function and balance as they relate to health, and those factors involve the anterior abdominal wall and its connections to the diaphragm, pelvic floor, flank, back and spine. Abdominal core surgeon is a more accurate description of the occupation, according to Dr. Poulose.
In addition, disease states that affect the abdominal core extend far beyond hernias. Intrinsic diseases of the abdominal wall also include diastasis, athletic pubalgia or core muscle injury as well as benign and malignant tumors. Extrinsic diseases include prosthetic and intervention-associated complications, and benign and malignant tumors.
What’s more, the field of abdominal core health has multidisciplinary scope that includes general surgeons (and associated subspecialists), plastic surgeons, physical medicine and rehabilitation specialists, exercise physiologists, physical therapists and those focused on disorders of the pelvic floor.
The Future of Ventral Hernia Repair
Dr. Poulose knows that shifting the focus of an entire field of medicine will be a challenge. “In general, people don’t like change and surgeons aren’t always the most flexible people in this world so changing things isn’t the easiest undertaking,” he says.
While he believes the next generation of surgeons will be more open to focusing on a holistic approach to abdominal health rather just identifying as hernia specialists, he’s also pleasantly surprised at the number of established surgeons embracing the idea. Ultimately, however, it will be a group effort that includes surgeons, government, industry partners and payers.
In 2020, the ACHQC began a new, national post market surveillance system to collect data on hernia surgery outcomes. Participation is free and members enter each of their hernia patients’ information at time of surgery and again at the 30-day post-op follow-up. Information collected includes outcome, recurrence, infection and any subsequent treatment or surgery. Surgeons who treat patients with longer-term follow-ups can easily expand a patient’s record to include subsequent visits.
“What has not worked in the past has to change,” Dr. Poulose says. “For us to really make a difference, we need to have uncomfortable conversations, but there’s a lot of promise.”