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Archive May 2015 XVI, No. 5

Customize Your Hernia Repairs

There's no one-size-fits-all best technique.

Bruce Ramshaw

Bruce Ramshaw, MD, FACS


hernia repair OPEN SUBJECT Constantly evolving techniques and products make it impossible for anyone to know everything there is to know about hernia repair.

The biggest advance in hernia repair in recent years has been the growing awareness that there's no one-size-fits-all best technique. There's no best mesh, no best fixation and no best approach to managing pain. On the surface, that might sound discouraging, but it shouldn't. When we accept the realization that biologic complexity and biologic variability make uniform solutions impossible, we take a big step toward better outcomes.

Everything in hernia repair is constantly evolving. What we thought was the right answer 10 years ago we now realize may be right for some patients, but definitely isn't right for everybody. Meanwhile, every year brings new ideas, new products and changes in old products. We can try to keep up through training and education, but it isn't realistic to expect anyone to know all the techniques, all the available mesh options and so forth. My focus is on hernia disease but I'm not perfect. The only way I can get better is to listen to patients, collaborate with other committed surgeons and keep learning.

In short, we need to adopt a systems approach. We need to collect and share data, so we can better understand and define the sub-populations who don't respond the way other patients do — patients who will be better served or possibly harmed by a given technique or a given mesh.

Focus on value
Hernia repair is a balancing act. A patient with a recurrent hernia is likely to be more challenging and more likely to have problems. You can virtually guarantee no recurrence by using a huge mesh and lots of fixation, but if you do, there's a good chance you'll be trading low recurrence for an increase in chronic pain. Conversely, you can use a smaller mesh and reduce the amount of fixation to minimize pain, but that could lead to a higher recurrence rate. In other words, if you focus on one goal, you tend to lose sight of other goals.

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