Hernia repair is one of the most common operations performed in the U.S. Each year, undergo ventral and incisional hernia repair and undergo inguinal hernia repair. Perhaps in part due to its ubiquity, hernia repair is often regarded as a simple, straightforward procedure that carries minimal risk and that virtually any surgeon can perform safely. In this regard, it is generally thought of alongside cholecystectomy and hysterectomy as a common operation we've gotten great at doing. Put another way, many see it as "just a hernia."
However, whereas complication rates have reached impressively low levels for these other common operations -- for example, current "" initiatives are working to even further decrease a bile duct injury rate that currently sits around 0.3% -- this has not been the case in ventral hernia repair. Complications related to quality of life continue to be common. One need only turn to billboards or late-night television to see a host of legal advertisements for hernia-related injury. Hernia recurrence -- the risk of the hernia coming back after surgery to fix it -- has been . For such a common operation, are outcomes really still this bad?
In the interest of answering this question, my research team and I performed a of hernia recurrence across a national population. In a cohort of nearly 200,000 older U.S. adults, we found that one in every six patients who underwent ventral hernia repair went on to have at least one more operation for hernia recurrence within 10 years. Importantly, because our study only measured how many patients got surgery for hernia recurrence, we almost certainly underestimated the true incidence of recurrence -- not all patients who have a recurrence choose or are candidates for additional surgery. In fact, at least one study suggests that reoperation underestimates true recurrence by . Equally concerning, compared to a from 2003 that found one in five patients underwent reoperation within 10 years, the current results suggest that even 20 years later, outcomes following this extremely common operation have only marginally improved.
In this context, it is crucial to redouble research efforts to understand the drivers of these outcomes and how to improve them. Ventral hernia is a common problem that makes up a large proportion of annual surgical volume and is associated with billions in healthcare spending every year. However, compared to other common conditions, "." If patient outcomes for this common operation are going to be improved, more research -- and nuanced research -- is needed.
So how can we achieve this?
One of the most obvious ways to continue pushing research forward in this realm is to capture the heterogeneity that exists in hernia management. Hernias come in all shapes and sizes, but in many databases, a patient with a small port site hernia and a patient with a massive infected incisional hernia both get coded as "ventral hernia." Therefore, accurately capturing this heterogeneity is paramount to improving hernia management. A number of efforts in the U.S. are already doing precisely this.
The maintains a national registry of surgeon-entered, voluntarily submitted hernia repairs that include fundamental characteristics such as hernia size, hernia location, mesh type, and a number of patient characteristics such as body mass index, smoking status, and diagnosis of diabetes, all of which are intimately related to hernia outcomes. To further expand these efforts beyond voluntarily submitted cases, the (MSQC-HR) was launched in 2020 to capture clinically rich hernia data at a population level. Akin to European hernia registries, the MSQC-HR will enable large-scale hernia research, but with the nuance necessary to meaningfully inform and improve practice. By capturing granular details regarding hernia size, location, mesh characteristics, and other critical factors, these efforts will help us understand the trajectory and outcomes of patients in the context of their hernia. Already, this effort has revealed in mesh use, operative approach, patient selection, and short-term outcomes like complications, which suggests there is ample room for evidence-based practice standardization and improvement.
Finally, it will be critical to augment these results with long-term clinical and patient-reported outcomes. As we found in our recent study, a patient's trajectory after ventral hernia repair plays out over years, not weeks. Longitudinal follow-up regarding patients' quality of life, functional limitations, clinical and operative hernia recurrence, and long-term complications like chronic pain and infection are needed to understand the full picture. To the extent that many of the outcomes following ventral hernia unfold more like chronic conditions than acute postoperative events, we must make routine collection of these conditions standard. Only then can we start to understand how changing something we do in the operating room can ensure the best possible result 5, 10, or even 20 years later.
To quote many hernia surgeons, "It's not just a hernia." As we've seen, not only is every hernia different, but they can affect patients for decades after surgery. Because of this, it deserves our utmost attention. There has been remarkable research to understand and improve the outcomes of patients with this pervasive condition. In light of new evidence suggesting that patients continue to face poor outcomes, intensifying these efforts at every level -- from local quality improvement initiatives to federally-funded research grants -- is warranted. Doing so may help us move the needle on this ubiquitous, yet continually challenging problem.
Ryan Howard, MD, is a general surgery resident at Michigan Medicine and Creative Director for Annals of Surgery. He is involved with research for the .
Disclosures
Howard receives research funding from the Blue Cross Blue Shield of Michigan Foundation and the National Institute of Diabetes and Digestive and Kidney Diseases.