Medical Optimization for Hernia Repair

Monday, May 20, 2019

Sean Watters, MD, FACS

Managing Hernia Risk is a Team Sport

As hernia surgeons, our perspective on hernia repair is often quite simple: the patient has a hole in their abdominal wall, and we must fix that hole. How each of us goes about performing the repair, in contrast, is often complex and heavily debated among surgeons.

What is not debated, on the other hand, is how critical the basic factors affecting healing are to the long-term success of any hernia repair.

Smoking, diabetes, obesity, and malnutrition are no doubt critical factors that can negatively impact many illnesses. When it comes to the modern management of hernias, however, the negative effects of those specific co-morbidities are even more intensely magnified. Success of repair and avoidance of complications hinges on the body’s ability to quickly and effectively establish collagen deposition and incorporate the light-weight mesh utilized for the majority of today’s repairs.

Elevated glucose inhibits fibroblast migration and propagates a sustained inflammatory state; one cigarette alone reduces the cutaneous blood supply by 40 percent; and obesity complicates all aspects of care, as we all know very well.

Putting this into clinical context, using a well validated pre-operative ventral hernia risk calculator (the Carolinas Equation for Determining Associated Risk or CeDAR), a patient who has a Hb A1c >7.3, BMI of 38, and is an active smoker has an associated 33 percent risk of wound complication from surgery. If they quit smoking, this risk decreases to 21 percent. If their BMI drops just 3 points to 35, the risk is almost cut in half to 17 percent.

Knowing these risk factors, we are responsible for informing our patients and proactively working with them prior to surgical intervention to mitigate individual risk and establish the optimal physiologic environment possible for success.

It is no secret that modifiable risk factors such as these are often the most difficult and time-consuming issues to treat in any physician’s office, which is why it is critical that surgeons work hand-in-hand with medical providers to set realistic and attainable goals with our patients.

It is not uncommon that consultation for a hernia initiates the creation of individualized goals in weight loss, smoking cessation, and/or tighter glucose control. When addressed in a team approach, these goals have led to long-term durable surgical and medical health success.

Patients invest their confidence in us to bring the most advanced medical and surgical care available to their ailments. We now have the luxury of solid evidence supporting the idea that the best investment we can make as physicians and surgeons is back into the health of our patients prior to surgery.

I take pride in The Oregon Clinic’s collaborative model of care provided to our patients with hernias. Every day, I see how thoughtful preoperative optimization coupled with advanced surgical techniques can pave the way to exceptional patient outcomes.