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Melanie Cole (Host): UAB Medicine recently joined the Americas Hernia Society Quality Collaborative. This relationship will allow UAB to participate in continuous quality improvement efforts to optimize outcomes and costs of hernia care. My guest to discuss hernia care today is Dr. Britney Corey. She’s a fellowship trained minimally invasive gastrointestinal surgeon specializing in foregut and anti-reflux operations and abdominal wall hernias at UAB Medicine. Dr. Corey explain a little bit about hernias. What had typically been done and what is different now?

Britney Corey, MD (Guest): Sure, so, hernias quite simply are an opening in the abdominal wall, the connective tissue or muscle layer of the abdominal wall. Although they can occur in the diaphragm as well. And so, traditionally, a lot of hernia surgeries have been performed open, but we have had advances in our minimally invasive techniques and so now we are able to offer laparoscopic and robotic hernia repairs and another great advance in hernia surgery is our postoperative pathways have gotten much better. So, we use a lot of multimodal pain agents. We work with our regional anesthesia colleagues to give our patients preoperative blocks and we are seeing our patients’ length of stays drastically go down and patients are able to resume their normal activities much quicker and get out of the hospital quickly and the ultimate goal is of course to get back to all of your normal activities.

Most patients are able to resume all of those within a week or two with the exception of heavy lifting which we ask them to avoid for about six weeks after surgery. So, our patients are doing better because of that and recovering quickly and of course we also have advances in the mesh that we use now for hernias. So, there’s constant innovation in the area of mesh and it’s getting safer than it has been in the past. And we also just have many options for the types of mesh and where exactly we can place those in the abdominal wall. So, we really, truly can make a very individualized plan of care for our patients now. It’s not a one size fits all. And that has really improved hernia care.

Melanie: So, before we talk about mesh and those changes; tell us about the Americas Hernia Society Quality Collaborative and what will this relationship allow UAB to do?

Dr. Corey: Yeah, the America’s Hernia Society is a society that’s both in North America, Central America and South America and what is allowing is for hernia centers all over the Americas to report their outcomes and the type of operations that they are doing as well as their thirty day and one-year results for elective ventral hernia repairs. And so, then that just give us a huge data set that we can evaluate hernia outcomes based upon. So, it’s big data and that will just help improve and further our knowledge about optimal hernia care.

Melanie: How is the success of hernia repair measured doctor? Is it – does it have to do with recurrence rate or something else?

Dr. Corey: It certainly has to do with recurrence rate. We definitely want a hernia repair to be long lasting for a patient. But it also has a lot to do with quality of life and so, many patients complain of pain at the site of their hernia or back pain because the integrity of their abdominal wall is compromised by the fact that they have a hernia, especially large hernias. And so, it is also making improvements in the patient’s quality of life. And so, them being able to go back to go back to their normal activities, to not experience daily pain, to not deal with an unsightly bulge also contributes to a successful operation.

Melanie: So, as long as we are discussing treatment, and optimizing; do you feel personally, that the current techniques of inguinal hernia repair are optimal and how does patient selection help you to optimize your repair?

Dr. Corey: Sure, so, for inguinal hernia techniques, there’s really two broad categories of how you take care of an inguinal hernia. Although you can divide it down until a lot smaller categories, but I think of it as an open kind of traditional hernia repair with mesh versus a minimally invasive inguinal hernia repair, also with mesh. So, I of course, I’m biased in the fact that I’m a minimally invasive surgeon, but there’s also data that supports that patients kind of resume their normal activities quicker and have less pain with minimally invasive operations. Both of those are outpatient surgeries, but if you have a laparoscopic or a robotic hernia repair, then we think that you are going to have less pain and research backs us up on that as far as especially laparoscopic inguinal hernia repairs. And you probably have a lower risk of infection which is a very low infection risk regardless, open or laparoscopic or minimally invasive, but we think that long-term, as we get more and more data; because that risk of infection is so low, it’s kind of hard to prove a difference. We think though, that we will see a lower risk of infection. Certainly, you have less scaring as far as your incisions are much smaller and most patients are back to their normal activities. Another advantage of the minimally invasive approach is that we can see both sides of the groin and so if you have a hernia on one side, we can also look on the opposite side and if we see a hernia that was not apparent on physical exam, we can go ahead and address it at the same time.

Melanie: Then tell us about how mesh selection for hernia repair can be challenging for you clinicians. Give us your expert review of the different types, the biologic, or synthetic or the bioabsorbable types. Speak about how mesh selection being a modifiable factor during the operation might optimize patient recovery.

Dr. Corey: Sure. So, I think of – I guess I will preface this by saying that mesh selection is a very individual surgeon’s decision and there are so many different types of mesh that in some ways, it’s very difficult to compare one to the other because they are – not only is there a lot of different types of mesh; but there are also a lot of different places that you can put mesh in the abdominal wall. You can put it on the outside of the muscle. You can bury it in the muscle. You can place it beneath some muscle or several other techniques that you can use there. So, it’s hard to be able to compare apples to oranges in large groups of patients which is another great advantage of being a member of the quality collaborative. But in general, I put mesh into three separate categories. So, there’s completely manmade mesh, synthetic mesh and that is permanent mesh, for the most part. So, once it’s placed inside, it will be there until it is removed, or you will live with it for the rest of your life. So, that’s great in that it is a very strong mesh typically. And you never have to worry about it going away and it can give you a long-lasting durable hernia repair.

But, on the flip side if that – it’s a foreign body and if it gets infected, then sometimes it even has to be removed and quite often has to be removed if there’s a complication with it. It’s going to be there the next time you have an operation, so your surgeon will have to work around that in the future if you ever need an operation. So, it’s certainly also tends to contract over time or shrink inside over time so, while it’s a great permanent and very strong mesh and we use them quite frequently; it has its downsides as well.

On the other extreme is the biologic mesh which is naturally occurring tissues and made typically in pigs or used from pig skin or even human tissue that has been modified for use as mesh and that – those biologic meshes are expensive but they also go away after about just over a year typically it will go away. Now they do likely cause some changes in the muscles or the tissues of the human body that can strengthen those tissues even after that mesh has absorbed or gone away. But certainly, whenever you compare manmade or synthetic mesh to biologic mesh; biologic mesh has a higher recurrence rate in most studies. So, whenever you are looking at recurrence rate as one of your successes of an operation; you have to take that into consideration. The great advantage to biologic mesh is that it fights infection very well. So, it’s very useful in patients who are at a high infection risk but have a hernia that needs mesh to repair it. And that can be patients who also have to have a portion of their intestines removed at the same time or etc.

Right in the middle is the bioabsorbable or also called biosynthetic mesh and that mesh is typically made of materials that – it’s manmade, but it’s made of materials that kind of naturally occur in the human body and so the body doesn’t recognize it quite as foreign. It also absorbs over time and so after about 12 to 18 months; you will no longer see it in the human body, but it will cause those changes to strengthen the muscles of the abdominal wall and so far, we think that its recurrence rates are going to be better than biologic mesh. We still need super long-term data on that, but the initial data shows us that it is probably better. It’s certainly cheaper and it also does very, very well with infections and so that’s why we think that it’s going to be a great option for our patients. And those patients that are at high risk of infection or who don’t like the thought of having a long-term foreign body or are having a portion of their intestines removed at the same time or something like that, that increases their risk of their mesh getting infected. That’s an excellent option for them.

Melanie: Wrap it up for us and thank you so much for explaining all the different mesh selection criteria for surgeons and how you all go about choosing that. So, wrap it up with your best information for other providers and what you would like them to know about optimizing hernia repair.

Dr. Corey: Sure. So, the conversation that I have with my patients in clinic whenever I am seeing someone for a hernia repair pretty much focuses on of course the type of operation that we are going to do; but what can we do to give you the best hernia repair ahead of time. And so, that is looking at all the essential risk factors that you have and saying which ones we can change. So, the number one reason that patients get hernias especially abdominal wall hernias is having a prior incision. So, we can’t really change that. Those patients have already had their incisions of course, needed their incisions, so, that’s in the past. We can’t change that. But what can we change? So, other reasons that patients get hernias are because of increased intraabdominal pressure and so the increased pressure in the abdomen starts looking for weak areas of the abdominal wall that it can push against and offload some of that pressure. And so, one example of how you have increased intraabdominal pressure would be pregnancy, but the reality is that typically our patients are dealing with obesity and that’s the reason that they are at increased risk of a hernia. So, if we can modify that risk factor, and lose weight before surgery; then that certainly will give them a better hernia outcome. Any factors that cause you to have weakened tissues are going to give you a less than optimal hernia outcome and so, the one there that we can modify is nicotine use. So, we encourage all of our patients to stop smoking and that is backed up by expert hernia recommendations that are published guidelines. And then finally, other things that contribute to poor wound healing and so, immunosuppression if you can minimize the amount of immunosuppression that any patients are on, but also the thing that we see most commonly is diabetes so we need to optimize our patients to have a hemoglobin A1c that’s less than 8 if at all possible and that will give them a much better hernia outcome.

Melanie: Great information. Thank you so much Dr. Corey for joining us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.