Hernia Rosen Heniford

Patrick:

Welcome back to Behind the Knife. It's Patrick Georgoff and Jason Bingham here. And as always, thank you for tuning in with us. There's a quick reminder that if you are in need of CME credits, check us out. It's completely free. Just head to the website or the app for more information.

Patrick: And today, we're Jason and I are joined by absolute titans in the field of hernia surgery. As I said, titans is Doctors Todd Henniford and Mike Rosenhouse fold names practically by now, especially on behind the knife. We're pleased to have you both with us. Welcome to the show gentlemen. Dr.

Patrick: Hannaford is chief of the division of gastrointestinal and minimally invasive surgery and director of the Carolinas Hernia Institute at Atrium Health Carolina's Medical Center. And Dr. Rosen is professor of surgery and director of the Comprehensive Hernia Center at the Cleveland Clinic. And so I think it's safe to say that these guys know a thing or two.

Patrick: about hernia. So when Jason and I recently read a paper in JAMA showing a five year recurrence rate after ventral hernia repair of greater than

40 percent in patients with mesh repairs and greater than 70 percent in patients without mesh, we knew we needed to get the real experts on the horn to help us make sense of these results.

Patrick: And I think more really, more importantly, to break down the What it means for the hernia surgeon who does not devote 100 percent of their time to the abdominal wall, but do quite a bit of hernia surgery. So, really, some of the questions that come up are we collectively failing our patients when it comes to hernia repairs?

Patrick: How do we counsel them? Should I prehab my patient? For how long? How much weight do they need to lose? Is the retrorectus space overplayed? Or is it the perfect place? We're a piece of mesh. What about E TEP abandoning the sack? What about anterior component separation? So in 2024, there's a lot for the hernia surgeon to consider.

Patrick: So let's get to it. We're going to use the paper as a launching point for it. I'm sure will be an absolutely fantastic discussion. Jason, you want to give us some of the key points and then we're going to

bring in our most esteemed guest to fill us in. Yeah, sure. So, as you mentioned, this is a paper that recently came out in JAMA looking at year over year ventral hernia recurrence rates and there's some associated risk factors.

Patrick: Now, it was a retrospective population based study using the Abdominal Core Health Quality Collaborative Registry to evaluate year over year recurrence rates in patients from 2012 to 2022. There's a large number of patients, 30, 000 patients with mesh and five and a half thousand with no mesh. As you mentioned, the findings were somewhat surprising.

Patrick: So five year recurrence rates greater than 40 percent with mesh and 70 percent with no mesh. What's important and we'll probably unpack this a little bit is the mean time from index ventral hernia repair to latest follow up was 128 days with mesh and 78 days for those without. And among patients who experienced recurrence, the mean time to recurrence was 495 days for

patients with MeSH and 330 days for those without MeSH.

Patrick: With regard to factors that was associated with a higher odd of recurrence, a lot of it was not surprising. Higher BMI, immunosuppressed, those with incisional and peristomal hernias, greater hernia width, use of resorbable meshes, and those with complications such as surgical site infection or reoperation.

Patrick: Some were more surprising, like a robotic approach had a higher odds ratio. For factors with lower odds, again, Not really surprising, greater mesh width, myofascial release, and hernias had a fascial closure. Interestingly the study found that smoking greater a SA class and prior mesh infections were not associated with a recurrence.

Patrick: So there's a lot to unpack here. So let's get into it. I think Dr. Rosen will start with you. Can you tell us a little bit about the abdominal core health quality collaborative? What is it?

Who participates? How, why was it formed? And what are its some of its strengths and limitations? Sure. So first of all, thanks a lot for having me.

Patrick: It's a pleasure to be here. I'm a hermit living in a cave fixing terrible hernias. The only way to get me out these days is to bring out Todd Henniford. So, I'm here, I'm happy to be here. I'm excited to have this conversation. For transparency, I am the medical director and I'm one of the co founders of the abdominal core, core health quality collaborative.

Patrick: So, my perspective, this has been around, this started actually Todd Henniford was president of the AHS or the next president of the AHS, It was incredibly supportive of this. I was a young surgeon trying to find my way, and we started this off more of a database where we could put our data in and share data, and it's morphed into several things.

Patrick: And now we look at it more as a quality collaborative where we have almost 500 surgeons across the country. Half are private practice, some solo private practice surgeons

out there, and people have major academic centers. And we basically, share our data for inguinal, ventral, and most recently we've added hiatal hernias.

Patrick: We have a lot of demographic detail, a lot of granular operative details, and we have really good 30 day follow up. But I think, as I'm sure we'll talk about in this paper, like everything in the United States, we struggle with long term follow up. And so again, I think all this stuff has to be weighed into what it can offer.

Patrick: I think the best way to think about the QC is that it gives you a 30, 000 foot view, what we hope is happening in the real world. We will never be able to prove that because obviously there's 16, 000 surgeons fixing hernias in the United States. So we have a small sample of that. I think we have a pretty good swatch of community academic affiliates.

Patrick: So I think we get close to the real world. But it, it's a place particularly for these type of analysis. To look at broad themes and then dig down

deeper into those to try and get as close to the truth as possible So what would you say is the greatest strength of the collaborative the greatest limitation?

Patrick: And if someone was interested in contributing What does it take to be a part of it and to contribute the data? Sure. Sure. So, The greatest strength of the Quality Collaborative, I believe, is that it allows you to track your own data and your own outcomes and see where you kind of land with people.

Patrick: It's also a collaborative. So, I mean, the concept of it is that we all share data. There's no advantage to being great. There's no disadvantage to not being great. We identify high performers. We learn from them and we make everybody better. So it's to shift you. I mean, I think one of the hardest things for everybody to accept in surgery, it's just like anything, it's a bell curve, right?

Patrick: We're all about curve. And so the goal of us at the collaborative is to shift you as far up on the bell curve as you can be, but recognizing that there will always be a bell curve. And I

particularly say that because there's often a concept of kind of the centers of excellence. Type of thing. You even insinuated in your introduction about experts, not experts.

Patrick: And I think that's actually a bad concept, particularly in the world of hernia surgery, because that kind of draws arbitrary lines based on outcomes and people gain the system. So this is really in distinction of that. This is just about, Share your data, become the best you can. So I think that's the biggest strength.

Patrick: The limitations are several. Number one, it takes time to put the data in and, it takes two or three minutes after every case trying to get patients to fill out questionnaires. It's not easy. It's time consuming. I will just put it out there that we actually have finally accomplished EMR integration in the quality collaborative.

Patrick: So you can now go. We can integrate with your EMR, and there's no actual work in the database. It happens automatically, so that's one of our hopes, is to relieve that barrier. I think the other limitation, again, is, we work with passive follow ups. We have several

mechanisms, emailing people, getting follow up in, in clinic.

Patrick: But it's hard. And, hopefully we'll talk about this, why hernia patients are not necessarily engaged. And follow up and why they don't participate. And finally, to get involved, it's really easy. It's totally free. You go to achqc. org and you join. There's a little bit of a contract process, which can be painful because we collect PHI, but otherwise, if there's one thing I put out there, like, it's a way to track your data and know where you stand.

Patrick: So you mentioned that the goal of this is to, show what's happening. What we hope is happening in the real world. I think the reason this paper caught so many people's attention was that high that really high recurrence rate was higher than people like to believe is happening in the real world or certainly, my record, certainly my recurrence rate isn't, greater than 40 percent or greater than 70%.

Patrick: So I'll open this up to both of you, how does this compare to prior studies that show different data or different recurrence

rates? What's different about it? And why do you think the study showed higher failure rates? Does it have to do with patient population? I know we need to get into that follow up issue.

Patrick: Is that the reason? Does it have to do with repair techniques, non hernia centers to perform in hernias? What's your guys just bottom line view of why it showed such high recurrence rates? I'll take that, Mike, to start with. And again, thank you guys for having us. And I'll give, I do want to give kudos for Mike.

Patrick: Mike has spent, a decade of his life building this database. And I guarantee he works on it every day. And when surgeons come up to me and say, how do I track my data? How do I make this happen for myself? I want to build a hernia center. The easiest thing to do is log on. You can easily follow your own data.

Patrick: You don't have to build a data set, and you get, you can get fancy reports from Mike and his group comparing yourself to yourself, comparing your growth and also comparing yourself to other people. So it's super easy to get started

with this. As far as if we want to get into this paper itself, I think There are certainly limitations in this paper and again, if you look at the patients without mesh, like one in 14 of those patients had fistulas or mesh infections, a tough, really a tough group and why they didn't have mesh and then you can look at the number of patients who had stomas and, if you want to make yourself look bad, follow your peristomal hernia repairs, and then the other consideration and probably the most important thing, and Mike and I've talked about this, is the follow up in this paper.

Patrick: Okay. And so it's hard to get patients to follow up, but if you want to talk about this paper and Mike is an expert in this and getting patients to follow up with the quality collaborative. But if you look at the follow up in this paper, the, and you mentioned the average follow up is 128 days for the mass group.

Patrick: But if you look at the average follow up until recurrence, it's 495 days. So it's, the follow up is not longer than the time to recurrence. So it's four times longer to the time to recurrence. And so with that, it makes, starts to break and then say it's almost exactly the same. That's a four

times longer follow up in the non mesh group as to the average follow up.

Patrick: So it starts to make you believe if you start breaking this down, that perhaps the patients who are coming back or the patients who have a problem, the squeaky wheel comes back and they got a problem, they come back and see their surgeon. If you look at the one year follow up in the mesh group, it's just over 15%.

Patrick: If you look at the no mesh group, the follow up is 7%. And so you start to say, well, what is our recurrence rate at one year when you only have 15% of the patients that come back? When you go to three years, it's 2% for the mesh group and it's 1% for the nom meash group at three years of follow up. So when 99% of your patients don't follow up, what does that number actually mean?

Patrick: And so who are those patients who are coming back versus the patients that don't come back? I think it, I think it speaks to the difficulty. In gathering data with long term follow up with patients will come into your office. They're nervous about their care. They've seen they were nervous about mesh and we did a study where we interviewed 200 patients before the surgeon saw him and 45 percent of the

patient said mesh equals complications out of the gate themselves.

Patrick: And they're worried about this, but then they won't give us follow up for their outcomes after they. Most surgeons are really good at fixing hernias. And the patients go out and you'd expect to do pretty well, and they don't follow up with their surgeon. So we don't want their outcomes are a couple things.

Patrick: I pretty much agree with everything. I'll give you maybe I'll add on to that just a little bit. I think. So, 1st of all, maybe it's just a public service announcement for everybody who's looking at papers in this paper. There's a Kaplan Meyer curve. And I think that, I mean, honestly, Jim surgery is incredibly high impact journal.

Patrick: And I think that, this was a miss, to be fair. The data is in the paragraph below, but every Kaplan Meier curve on the x axis should have the time, which this does, and then below it, it should have the number of patients that actually have follow up. And so the data is there,

it is there, but it should be on the graph.

Patrick: And I think that's to me, I mean, what this paper shows, Is it is you always have to couch this in the fact that this is QC data because QC data and it can always you can't win the argument, right? It's either It's a bunch of experts who aren't the real world or you know It's a bunch of people who can't follow their patients up.

Patrick: And so remember these are 500 people Who are super engaged in hernia surgery, who care enough to put data into this database to be, at the top 1 percent of people who are doing this stuff, just by effort, not saying outcomes, but by effort just to do this. And I think that's one of the things my message to everybody is we have to get comfortable understanding that we don't know the answer.

Patrick: Right. And that's hard to do as a population, right? Because if the most engaged people in the United States. Can't get more than 10 percent follow up. That's a problem.

And I have a, we'll talk about it. We'll have, I think one of the, one of the problems is the way we couch this disease to patients. But I'll add one extra thing just as a little kind of controversial comment is again, I don't think this data tells the whole truth.

Patrick: Like I want to be clear about that. Cause as Todd said, we're missing a ton of follow up, but if you ask everybody in the world, why they use mesh. The reason why they use mesh is because the Lewandyke trial, which is one of only four hernia studies ever published in New England Journal of Medicine, and shockingly enough, their recurrence rate in the mesh and no mesh group is actually exactly the same.

Patrick: The same as this study, and to add on even to that, that they had, they were dealing with hernias that were substantially smaller than they were dealing with three or four centimeter hernias. So, hopefully we'll get to

delve into this, the story of we found the radical cure to hernia, and let me prove that I'm right for the next two years, and then prove that I was wrong for the next five years.

Patrick: That story has been told over and over again, certainly by me. Maybe a little bit by Todd. And I think that, again, I don't think that This trial shows that for sure, but it always strikes me how people forgot that although we all quote 2 percent recurrence rate, we're using mesh because it reduced the recurrence rate from 60 percent to 30%, not 2%.

Patrick: And that's our level one, probably the best highest impact trial ever written ever in hernia surgery. So, so, again, No question, you got to look at the literature carefully, but it always shocks me how easy we are willing to walk away from some of the best data we have. Well, if you look at that study, Mike, and that Luendyke study with Hans Jacobs, the senior author, changed hernia surgery.

Patrick: It launched a revolution of

the mesh industry. All these meshes that have come out, launched since then, it falls back to that paper. You guys know what the fragility index is, right? You have two things that you're testing. You have a recurrence in one group, a recurrence in the other group, or no recurrence.

Patrick: But if two people, in this study, if two people either had a failure or didn't have a failure on one side or the other, This is no longer statistically significant and the hernias were six centimeters and the largest turning was six centimeters as Mike talked about and you know how they fix their hernias?

Patrick: They whip stitch a piece of mesh in the middle of it. Wow. It's just a small. What year was this study? New England Journal of Medicine in 2000. We'll put it in the end. And that launched, revolutionized hernia surgery and launched an industry. Not a small and you can forget. I mean, and again, I mean, to Todd's point, like, it's different techniques, but I mean, again, like, to me, again, I mean, hopefully we'll dig in this a little more of it.

Patrick: Right? Like, What I think we forgot as

we have like embraced mesh and outcomes which, I mean, I think it's appropriate to fix hernias with mass. Like, don't mistake what I'm about to say, but what we've forgotten in all of this is the disease of hernias, right? And how hard It is to treat this disease.

Patrick: Right. So this is, yeah, this is exactly where we wanna go with it. Because the question then is, are we as surgeons collectively lying to ourselves failing or missing the greater point when it comes to the disease process? And so exactly how do you both, as ex true experts in this field, and people have thought about this so much.

Patrick: How do you think about it yourself? How do you teach your trainees and how do you talk to your patients about it when it comes to this bigger picture of hernia as a disease process and how you approach it surgically, especially as just one one part of it. Okay, I'll start with that. So, so I, I've changed tremendously over the years in this and I

have to tell you that I think that part of is just getting a little bit older, a little bit, more mature and having a little bit of perspective and like facing failures, right?

Patrick: I'm like, as Todd said, like, if you stick around in the same place long enough. Follow up is humbling. And so, so I think that when I was younger a lot of what I thought about and what I wrote about was truly to show how good I was as an individual, right? And like, look what I can do. And it's amazing.

Patrick: And I think many people that way, again, I mean, I think that's actually fine. Like it's surgery. You should. But as you look back in time, you realize, and I think that, and this is what I'll tell you is, I think we need to completely have a different conversation with patients. If you go see your orthopedic surgeon, as Todd and I are getting older and have to see them at times, and they put a hip, I'm sure Todd has two hips and two knees by now but if they put hips and knees in you and shoulders, they tell you straight up.

Patrick: This is going to last you five years, 10 years, you're going to need to have it

redone. And there's no conversation about, well, that's because the prosthetic isn't good. And that's because I'm not a very good surgeon. And that's because if you went to see a really good surgeon, it's going to work better.

Patrick: It's a high mechanical strain area. There's a lot of load. There's a lot of things that are happening and these things break down. And now, I don't know if it's exactly the same but, I try and set a realistic expectation with patients and say, Hey, look, this is a tough disease.

Patrick: Like I'm gonna do my best. And I would just like what I tell faces if you just want to know about recurrence. Is which a lot of people focus on recurrence, which I don't think that's really what we should be looking at. But when people ask me about recurrence based on my data, I say, hey, people say, what's the chances?

Patrick: My hernia can come back. I say, well, you know what? It's a much more complicated question than that because it depends on perspective. If I ask you, what's the chances? You might have a bulge after my operation. Will you complain about it? Probably 25 percent. You're going to notice some asymmetry.

Patrick: You have a hernia. There's something wrong with your abdominal wall, and I'm not going to make all that go away. If you, if I get a CT scan on

everybody, maybe one in 10 chance, I'll find some small that doesn't bother you, but maybe about a three or 4 percent chance you're going to need another operation for it.

Patrick: And so again, depending on the perspective, it's much, much more complicated than just one thing. And I, but more than anything, I really think if we set it up to say, look, this is a chronic disease. So when I call you and ask you for follow up at three to five years or 10 years, It's important that you let me know how you're going, because things can happen over time, and if we just change that, and it doesn't mean we're bad, it just means that, just like Balazs said, like obesity, right?

Patrick: We thought we cured obesity with all this bariatric surgery, sleeves, whatever. It's not curing anything. It's a long term disease that is constantly having to evolve to make it better. And as surgeons, if we got away from the one and done, And we're going to take care of you throughout the continuum of this disease and thought about our surgical approach in that way.

Patrick: I think it'd be much better for patients and much more realistic for us.

I think Mike's right. And so what do I tell my students and residents and fellows? First thing, buy Mike's textbook. It's the best in the world. You're welcome, Mike. And then I second that. It is a pretty remarkable text. Here's to a video hernia atlas on Behind the Knife in the future.

Patrick: Just planting the seed now. So let's go. Let's go. The but I think that one of the things that the surgeons have to understand, and I'll start with the surgeons and I start, I tell the same things to our, to the, to our trainees is that new people in your office for a reason. And I'll say this to the patients as well.

Patrick: If new patients, and we're just talking about incisional hernias and patients who develop an incisional hernia have separated themselves from the herd. If 18%, let's just say you develop an incisional hernia. They're there for a reason, and most often it's not because the surgeon closing missed a stitch or something of that sort.

Patrick: And when we look at our data, the patients who walk in our office, let's just say that the patients we looked at about 800 patients had component

separations. And when we write about this, we write about the whole group, and it's a very complex group. But then we want to figure out what we're doing is works.

Patrick: Now, we eliminate people, the body mass index over 35 people than contaminated wounds. People were where we couldn't get the fascia closed. People with who were active smokers and uncontrolled diabetics. You start eliminating those people were down to 22 percent of the population of the patients that we wrote about.

Patrick: I out of the gate, these people are complex. And if you look at all the incisional hernias, we looked at almost 1000 consecutive incisional hernias, not just component separation patients. And then you add into it defect greater than 200 square centimeters, and you add in immunosuppression and in those sorts of things, and off midline hernias.

Patrick: Now we're talking about, almost 84 percent of the people that we see. And so these are complex patients walking in the door, complex operations, and you have to give credit, or you have to give it its due, let's just say. Not, it's not just a hernia. This is a complex operation in a complex patient.

Patrick: And I tell the patients, much like Mike said,

my number one thing that I want to do is one is to keep, most importantly, to keep you safe short term, keep you safe long term, protect your quality of life is two on that list. And then thirdly, is recurrence that we worry about. But if we can get, if we can make patients better patients, and we may talk about comorbidities and that sort of thing, but we can take complex patients and make them better patients and influence their outcomes.

Patrick: And I don't think there's any question about that. So I really like that, that approaching this as a chronic disease, and I love the way you guys laid out, how we should be, talking to patients to follow up on that, then how do you, what are the, you touched on this, Dr.

Patrick: Rosen, but just to more explicitly lay out, like, what are the things that we should be following, how long do we follow, do you guys follow your patients, your hernia patients? What are you looking for? Do you image them? Routinely at some set interval, or are you more focused on long term quality of life?

Patrick: How long do you fall them out? How frequently

and what imaging if at all do you get? Yeah, let me fairly answer that for me. And I think probably Todd's probably the same way, but let me also answer that for like the realistic, with 99. 9 percent of hernias that are being fixed by general surgeons in the real world, what is a reasonable expectation, right?

Patrick: So me personally, I try and see everybody back at one year and get a CT scan. I think probably, I mean, if I get 50%, I'd be surprised but we try. And then, I'll try, I would love if I could get imaging every year. That'd be great. I mean, I write a lot of papers. I want to know what the truth is.

Patrick: I want to know what things are. So I'm actively seeking that stuff out. And we try to get, we email patients every year, these patient reported outcomes with quality of life metrics, pain, and whether or not their perceived recurrences are. So like we actively do that but, it's not easy to get that follow up.

Patrick: And so I think for the real

world surgeons out there. Outside of being in the collaborative where we're emailing your patients and still the response rate is 15 to 20%. It's unfair to ask them to see all these people back. So what I think is a fair response is what I insinuated before, which is just to accept the unknown.

Patrick: And accept that like, look, we're doing a lot of these cases and like, we don't know what the follow up is. I'll add one thing, though, that I would have liked to see this paper to do. And maybe it could be done in the future. Again, with limitations. But there's another thing that we do in the QC that we just recently.

Patrick: is really championed this is we can now link Medicare and Medicaid patients to the QC. So it's roughly, we have about 150, 000 patients in the QC and about a third of them are Medicare and Medicaid patients. And so what that does, the limitation is now you're just Medicare and Medicaid patients.

Patrick: So that

introduces some bias. So it's not perfect. But what that does do is that we can get almost 100 percent follow up. And remember, we know everything that happened in the OR that they don't know with the CMS data. But now we have a true re operation rate, and we can actually calculate mesh related problems long term based on different ICD 9 and CPT codes.

Patrick: So, so then you get to like near 100 percent follow up. Of 30 percent of the patients. So again, not perfect, but getting yourself there. And finally, I think, just acknowledging that, like, measuring recurrence is hard. Is it reoperation? Is it the quality of life and all those type of things?

Patrick: And then I think he's got to get comfortable realizing that and then look at the literature. carefully and realized that, a lot of people, when they report the 2 percent recurrence rate and all that stuff, they're missing tons of their patients. This happens to show it the other way, because they're only picking up people who show up with problems versus

assuming that if you don't show up, everything is fine.

Patrick: And so, it's funny if you would have taken this paper, right, and, And you played it out the other way just to show you how data can be used however you want And let's say that you just assumed that everybody who didn't follow up was okay Then you would have a one percent recurrence rate at four years a two percent recurrence rate at five years So it just shows how hard it is to sift through How people take the data and present it in a way and both are fair and accurate But they will just draw the opposite conclusion.

Patrick: And so those are wildly different, numbers you'd mentioned some percentage , a possible recurrence is on imaging or clinically significant recurrence is requiring. reoperation, that's a far cry from the numbers were tossed around in these studies here.

Patrick: And the vast majority of surgeons doing hernia surgery are not going to be able to see a patient at one year, let alone, get a CT scan covered and, or convince a patient to undergo some more radiation for the sake

of taking a look, as valuable as that may be.

Patrick: And you said, except the unknown, is it as simple as that then there's that big space where it's like, I don't know, I don't know what the hernia rate or my recurrence rate is exactly, clinically significant recurrence rate is. Am I just going to undersell and over deliver?

Patrick: Is that all it is in terms of my preoperative discussions? And accept that there's a, an unknown maybe it's 10%, maybe it's 20%, maybe it's 30 percent the rates that you're going to throw out there. And well, my take on that is really easy. Might be a surprise. Patients love honesty.

Patrick: I think it's okay to tell a patient. Hey, look, we don't know. I'm gonna do my best with what I know today. I'm gonna try as hard as I can. But like, hey, when I call you in a year and want to know what's up, it's important that you talk to me. And it's important that you let me know where you're at. Because the truth is, We don't know.

Patrick: And like, it's been shown over and over again. Like in the United States, we don't

know in Europe, all they really know is what the reoperation rate for recurrence is. They don't know what the patient's quality of life are. They don't know pain. They have good administrative databases. So I, again, I'm an eternal optimist.

Patrick: I just see this as all the young people out there listening to this podcast. This is it. This is your future. Figure it out. Find a way to get this follow up. Make an app, make an AI, make a way like, like just, it's okay to say we don't know and somebody go figure it out and don't just accept that we know.

Patrick: Well, I'll respect and disagree a little bit in this and that when Mike you have that you have the privilege of. Of stating this and I think we should always be honest with our patient. Absolutely. But when you start to talk to patients, honestly about not knowing and what those outcomes are, most of your patients referred into you and you're the last you're the last hope.

Patrick: When I see patients, they go, you're my

last chance. The patients that we see on average have had three and a half failures. And they're like, whatever you tell them, they're like, we're going to be with you no matter what. And so, physicians should be honest no question about it. But you have the privilege of, I mean, they're with you, no question.

Patrick: The, how we get follow up is we often, and especially in patients who are from out of town, we work with, we'll work with their family doctors. And we, physical exam is what we go by. It's hard to get patients re imaged. It's hard to get insurance companies to pay for it. And then it's hard to do it in a really organized way, where the numbers actually mean something.

Patrick: So if you get 20 percent of your people, you get CT scans. And 40 percent of them, you get a physical exam. And so, what does all that mean? I mean, you can make something out of that. But we, for the most part, go by physical exam. And if someone complains of something, then we'll CT them. Or we'll ask for them to be seated at home and I want to see the films and there's lots written and discussing whether a radiologist sees a hernia or doesn't see a hernia and Mike's actually written some interesting things

about hernia surgeons looking at CT scans but hernia surgeons looking at CT scans are better at diagnosing hernias than radiologists are because they don't really look at them.

Patrick: Or look for them. They're looking for your cancer or your adrenal mass or whatever. And so, it's, we work with the family doctors in, in physical exam and we're, quality of life, lures us to like, get a deeper dive in these patients. Absolutely. And we want to learn from this and we won't give ourselves a pass.

Patrick: And when I talk to patients, every single patient I talked to, I said, the reason I can talk to you like this is because the patients who came before you we've tracked 22, 000 patients and the patients who come before you have made me a better doctor because I, I give myself a report card at every opportunity.

Patrick: And I have gotten better and have strived for a good report card. And this keeps me motivated, keeps me honest. And also the changes that we've made over the last 25 years, and we can track those compared to what we used to do. And all of this, it's you don't want to. You don't want to live and It's a suspended animation in your practice.

Patrick: You want to keep

learning from your own practice, and you can learn from people like Mike, perhaps from me. You can learn from other experts, but even if like you compare it to like computer chess, the stockfish that learned from all the masters games and beat the international champion, then played AlphaZero, which was Google's computer game that played itself over and over again, learned its own weaknesses, never learned anything about the rules, but played itself.

Patrick: AlphaZero then beat Stockfish 28 times in a row. And so you can learn from us and get better, but learning from your own mistakes and your own data is the best way to grow. And again, I'll fall back to, like, you want to learn from your own data? I mean, you can plug into the Quality Collaborative and be able to track your own data, pretty effectively and efficiently.

Patrick: How do you guys think we're doing? I mean, I think, so I think this is, I'll preface this by saying, I think it's a super exciting time for, I mean, hernia surgery is sexy. I mean, when has, I don't think hernia surgery has ever been as

sexy as it is right now with all these online communities, all these online communities, new techniques, videos, everybody's excited about surgeries.

Patrick: You guys, are both. hernia monsters that are at these tertiary referral centers. What are you guys seeing collectively? What's your sense of how we're doing as a community or do most surgeons understand the basic principles? Are we following the core principles of perineal surgery on the whole, or do we have a lot of work to do?

Patrick: I mean, I, so it's, I mean, I'm going to steal a line from Todd. Like we're both of us are sitting at the bottom of the funnel. So our life and our perspective on the world is jaded. I think it'd be fair to say. I, I. I would say that it is equally exciting to me how sexy hernia surgery has become, but equally concerning to me the side effects of

that and the potential influences.

Patrick: upon surgeons in some of the choices that they make and understanding who's driving the conversation and who's driving the bus. And so, I think it's just like, it always comes back to me of just understanding yourself, understanding what you're doing. And I agree with Todd, like I, it isn't fair for me to say, Hey, just tell everybody you don't know, is this, cause I'm just saying when people come see me, I'm going to be operating on no matter what I say.

Patrick: They're just like sign me up. So so that's important to acknowledge that but I also like maybe I would say it backwards Like when somebody comes with the newest technique the newest mesh the newest layer to put the mesh in the whatever just take it with a grain of salt because we don't know Right, and so you don't need to be rapidly going on to the next thing and I do think That I would say that what concerns me the most about hernia surgery today Is that we are applying very advanced techniques to somewhat routine hernias,

both open and robotic, and it's not a bash on the robot, but in all different ways.

Patrick: And I think understanding the thresholds of when we do things and like, if you listen to us talk about what we do every day, yeah, I'm doing big operations every day because that's all I really ever get to see anymore, big hernias. But if I see a small hernia, I'm doing a lap eye palm. I love it. I just don't get to see those cases very much anymore.

Patrick: And I'm not gonna make a big deal out of that and kill myself to get the mesh. outside the peritoneal cavity. So, so I, I think that, with the lack of good data to guide these decisions, just looking at some of these newer things, just, taking a pause and letting the data build up before we rapidly adopt them is probably best for patients because I'm sure Todd is the same thing.

Patrick: I mean, 50 percent of my practice, is redo TARS and redo retromuscular surgery, which is challenging, complicated, and the results are not very good

and their palliative operations and the patients are being hurt. I mean, many patients are being helped. Don't want to undersell, undersell that, but there are a lot of people being hurt by where this field is going.

Patrick: I think that we'll need to follow up just a bit with what Mike said is that, technology is not useful until it's boring. And so 1 of the issues that we have in surgery, and I'll just say a lot of space as humans, but surgeons are competitive surgeons, have ego surgeons of, don't want to be last in the pool.

Patrick: And so, but you know what we need to do is like you can take robotic surgery when it came out and you got a lot of people jumping in the pool and swim around trying to figure out how this works when what we should do is let some really talented people get in there, work it out, tell us how to use it and then go from there.

Patrick: And so technology, it needs to be, when it's boring, it's useful. And I mean, same thing, the mesh has come out and there'll be no data whatsoever. And there's one

particular mesh that was launched in 2013, no data until 2018. 160, there's 165 million spent on this mesh, 39, 000 patients treated, and we had zero data points, not a clinical data point.

Patrick: That's not the mesh company problem. That's a surgeon problem. And just to back up what Mike said in that. And I think that we're doing better. And 1 of the reasons I think we're doing better, I'll skip back to your question, is if you look at the data, we're actually now, when, as opposed to when I first started this, we're reporting more complications and more recurrences.

Patrick: And you say, well, how is that better? I think because we're being honest. Until surgeons become honest in their data reporting, you can't get better. One of the first times I was ever in the American Hernia Society and I won't give specific numbers, but some of the surgeons sit up at the front of the room and 400 cases, no recurrences, one wound complication, everybody's just like perfect.

Patrick: And I was standing back there and I said, we should stop everything we're doing going forward because that's

perfect. We should do that repair forever. And, but being honest and presenting data like this paper that Jeff Janis and these guys have put together, what they're trying to do is be honest with this and here's the data we have.

Patrick: It's not very good, but this is the data, the best data we got. So let's just, so let's talk about it. But I also think that, and we're producing some pretty good hernia surgeons out of Mike's fellowship is fantastic. And you've got Igor and Yuri and Christy Harold and some others around the country, really producing some true hernia superstars.

Patrick: and they're diffusing around the country. And I think we're gonna see an improvement. But we can't people like that are hernia fellowship. Big hernia train can't fix all the hernias. We couldn't fix them all if we wanted to. And it is our responsibility to train good general. Sure, the best operation performed at home.

Patrick: And so the good general surgeon can do it. Any operation in their home hospital. It needs to be performed there, and it's up to us. To help train people to do that. I'll echo what Todd said just to his, I think there's maybe like

worth discussing too about like, what should the average general surgeon be doing?

Patrick: Should we be having centers of excellence? This always comes to that. I want to like completely agree with Todd too. I mean, like you cannot take away hernia surgery from general surgeons. I mean, this is their bread and butter, meat and potatoes. It is completely unrealistic. So, so what I would say.

Patrick: What we should stop doing is telling the kind of real general surgeons out there that you need to do some of these advanced complex procedures for what they can repair with their routine methods right now. And it's hard to draw the line where something becomes complex, but we all know it when we see it.

Patrick: And so complicated things, yeah, those should go to the centers where people do this stuff all the time. Just like, we don't have centers of excellence for pancreatic surgery. Esophageal cancer surgery, because we just accept those are really hard operations. Most people don't want to do them It is somewhat of a natural thing in

hernia surgery that when things are truly complicated Most people don't want to deal with that.

Patrick: But yet we have you know spots and folks that are very interested in it But I think we have to be careful because cannot take away the lifeblood and how these people feed their families for doing general surgery and fixing hernias and let them do their eyelids, let them do their open eye palms for small routine hernias, it's okay.

Patrick: And the results suggest that, for the routine things, that's a fine first approach. So when it comes to ventral slash incisional hernias specifically, what is routine and that's not a totally fair question, but to some degree, what is routine? And then when it comes to that, then what are the core principles to approaching those patients in terms of workup and then decision making when it comes to types of repair?

Patrick: And again, that's a, that's broad but there are some core principles. I know that I've heard both of you talk

about that. We'd love to hear. I'll just say that as far as truly the core principles. And when I talk to patients, all the time, what I tell them is, there are a few things that are super important.

Patrick: One is about wound complications. If I can eliminate the infection in you, if I have an infection in you, my recurrent traits, 3. 1 times higher. Right. And I need to get your fascia closed. If I don't get your recurrence rate is seven times higher, long term. And I need to put a broad piece of mesh behind your abdominal wall.

Patrick: And we've seen, and we do a lot of pre peritoneal hernia repairs. And one of the reasons we've fallen under pre peritoneal, even in multiple recurrent hernias, we can do a pre peritoneal hernia repair in over 90 percent of those patients. And it's because we can put a broad piece of mesh in their abdomen and xiphoid to pubis if necessary, and you can go as wide as you want in these patients.

Patrick: And if I can get those core things done when I talk to patients, then our chance of not having a hernia occurrence is

really high. And so we've worked out what mesh works really well for us as far as permanent mesh goes and those sorts of things. And we've stumbled a little bit in the past using lightweight mesh in the ventral abdomen.

Patrick: We saw that our recurrence rates was higher than that. We've eliminated that with our follow up. But those are the three core principles. And then you can go back to Well, how do you decrease your wound complications? How do you get the fascia closed? What mesh do you choose and what plane do you put it in?

Patrick: And then around those three principles, you can wrap around the other core issues that make for a good hernia repair. Yeah, I think I would say, I mean, I think the most important core principle, like any surgeon is first be a good doctor. So like, as Todd said, I think, make sure your patient is as optimized as they can be.

Patrick: And that's obviously controversial and we don't want to delay or withhold surgery, but you need to be a good doctor because you are there. And then I think, I like to tell patients there's three things in every operation, right? There's a patient, there's a

surgeon, and there's a prosthetic, and. If you rank those three in order, I think probably the surgeon is number one.

Patrick: Okay, so whatever Layer you put the mesh in whether you do an open lap or a lot whatever you do If you are doing good surgery, your results are probably going to be just fine For the right patient and whatnot and the right size defect. And then obviously there's all the layers of the size of the whole, whether you need releases and all that.

Patrick: I will say again, I said this before, but I'll just reiterate. I do think that there's been a trend to blurring the lines between for open complex cases. There's no question. Whatever mess you choose. It's probably better than retro muscular position but applying those principles to small routine hernias I think that's a bit of an overstep particularly using minimally invasive Approaches so I think that if there was one thing I would say is Again, for small routine hernias, the layer of the mesh that you put it in

is probably overstated significance.

Patrick: Bigger hernias, no question about it. But in bigger hernias, we're worried about infection and all that stuff. What's small and big? Just throw out a few numbers. I'd say less than five to seven centimeters in width. I would say is that the five centuries is probably a, small to me where you have all the MIS options available seven to 15 is where you better be prepared to do some extra things.

Patrick: Anything over 15, this better be something you do quite a bit. So let's talk about that 7 to 15 really quick because I think that's an interesting place to be when it comes to Let's stick with an open ventral incisional repair 7 centimeter greatest width Maybe a small fat containing second hernia a little bit farther up, at the midline.

Patrick: So again you're in clinic and you're with your trainees, you're looking at the CT scans. Patient's got a BMI of 35, no major

other major comorbidities. This is a recurrence, there's no mesh and no, let's say there's no prior mesh. How do you walk through that and talk about, when it comes to, you mentioned retrorectus, you mentioned that we've talked.

Patrick: Dr. Hannaford, you mentioned specific mesh types and when it comes to permanent mesh and you've learned things over time wax poetic a bit on that patient. I mean, again, there's no, obviously every patient's different and very highly specific, but you want to take it first. I'll check it out. Well, sure.

Patrick: The to 1 of the 35 and there are other things that would go into this and then 1 would be is like, how much of how much is outside the abdomen? If you can have a seven centimeter defect and you can have tremendous loss of domain through that, or is there just a small bulge? And also to is you mentioned no code morbidities.

Patrick: What does the abdomen look like? What's the skin look like? Those things play a role. If this, if you're going to do a minimally invasive surgical

repair, but the hernia comes right up to the skin and you have really thin skin over the top of it, that goes into my decision making of open or laparoscopic, or even possibly robotic.

Patrick: But when I'm looking at the, at this patient and talking to him, one BMI of 35 for every point of BMI greater than 26, not 25 for us, but 26 and looking at our data. And now we've repeated our data with 1800 patients. And again, it was a BMI, anything over BMI of 26, you slightly increase your chance of wound complications.

Patrick: So I have someone with a BMI 30. And I'll say, can you use a little, lose a little weight? I'm going to, I'm going to, I'm going to hedge my margins and everybody. I mean, you guys are pretty fit looking right here and I'll just say, dude, can you probably lose a little weight for me before I operate on you?

Patrick: Because we're going to drop the BMI point, you decrease your chance of overall complications by 6%. And so that person, can you lose weight for me? And I'll say, any weight you can lose will help me. The other consideration is, as far as mesh choice in that patient, I'm going to use a permanent synthetic.

Patrick: And

most, most often with our data will be, it would be a polypropylene, mid weight polypropylene mesh in that space. We're going to, most often we will, Mike we did lots of laparoscopic ventral hernia repairs when you were in Charlotte. But in this space, in this patient, typically we do an open pre peritoneal.

Patrick: If the rectus muscles, I'll look at why the rectus muscles are. That's my fallback. If the rectus muscles are four centimeters wide, like Dr. Rosen's, I'm like, I'm not doing, I'm not doing a, I'm not doing a rectus repair. I mean, we're going to, we're going to do a pre peritoneal repair. And like, if you're going to do something, one of these robotic repairs, like retrorectus, that wouldn't fit either.

Patrick: So looking at the width of the rectus muscle makes a difference and helps my planning. Previous operations, and can we get in a pre peritoneal plane? And and then I'll ask the patient what they want. Do we, does the patient actually need an operation? One thing we know, if you've got a seven centimeter defect, let's just say the seven centimeter defect, and you mentioned her hernia a little higher up, Like it's in a laparotomy incision, but they got one hernia and then

another hernia above it.

Patrick: What you would expect over time is that your oblique muscles. We're going to pull that wound open and so they're going to they're going to tear it slowly tear this wound open. That's how her knees get bigger and bigger over time. They're going to compress your abdomen and we've seen in patients in this description as a patient watch is watchful waiting appropriate in this patient.

Patrick: My response to that is no. I mean, we're going to do watchful improvement in getting this patient ready for surgery. And then I will tell the patient, you're need, you're going to need to have an operation because your hernia will get larger. No question. And we found, we followed almost 1200 patients with multiple CT scans in 18 months.

Patrick: The average increase in size of the hernia was over 80 square centimeters and over 500, over 18 months at 18 months, 80 square centimeters, 80 square centimeters increase in the size of the defect and also 550 cubic centimeters of loss of extra abdominal hernia volume. So now

what you've done is created another animal.

Patrick: These are in lab patients who've had previous laparotomies. And so if you've got a small primary hernia, that's not going to grow very quickly. And, umbilicals, epigastric, say that because the rest of the fascia is intact and it hasn't been lacerated. It hasn't been injured. It's not crystalline and it's healing, but these hernias will get larger over time.

Patrick: And that data was done by Katie Slosher when she was in our lab and published in surgery. And or surgical endoscopy rather. And I'll tell you, it really changed my approach to the patient. So we, when we tell patients to get ready for surgeries, smoking, diabetes, weight loss and those sorts of things.

Patrick: We now call the patients. You typically at four to six weeks. How are you doing? How's your weight loss? Like, how can we help you here? Go here. Describe that. We previously described the ketogenic diet. Is it working for you? If it's not working for you, we'll advance to a dietitian. That doesn't work for you.

Patrick: We'll advance you to a bariatrician. Can I talk directly to you and to your endocrinologist, your family doctor to help you get to the point where you're an improved surgical patient expecting better outcomes because we've been, we've

prehabbed you, but we're going to, we're going to keep chasing those patients now.

Patrick: We don't so go get yourself right and then come back when you're right, and people will come back with a tremendous hernia. I don't know if that's your experience, Mike. Yeah, I mean, I think I pretty similar. So listen, seven centimeter defect back in the day, no question that would be a lot ventral. But I think again, like the same stories we're having now, that venture was overused, the pendulum swung way too far.

Patrick: So for me, if it was just that little defect up high in the BMI at 35, that'd be the lap ventral for me. Like, a two or three centimeter defect in an obese patient that's symptomatic, that's, to me, that's a perfect lap ventral eye palm candidate. Seven centimeter defect, that's gonna be too big for me.

Patrick: So, I actually, I want to like expand on one thing that Todd did mention, which is the minute you start messing around in the retro muscular space, whether open or robotic when you're not as experienced with it, what you realize what people have a hard time understanding is. And we've done some work on this,

that when you release the posterior rectus sheath to do the retrorectus dissection, that's helping the midline come together, but it's not helping the posterior sheath come together.

Patrick: And so as soon as you mess around in the retromuscular space, The Achilles heel of all retromuscular surgery, TARS, all that stuff is posterior sheath breakdowns and then you get these internal hernias with bowel and mesh. So what the surgeons often find, open or robotic, is all of a sudden the posterior sheath won't come together and now you're stuck in a TAR where perhaps you don't know how to do it, you're not as experienced, and you're compromising.

Patrick: So, so I actually think this is, it's a great example of this prepared neo hernia repair. I mean, it has its own challenges, but it avoids. Having to mess with the fascial releases so that you can get posterior she closure and do your extra muscular or extra peritoneal subway repair. So again, if it was me personally, again, unless

the rectus muscles were, very wide, like 9, 10 centimeters.

Patrick: It should be uncommon in a hernia patient, then that patient's probably going to be getting a tar. And I won't compromise on the posterior seat closure. And that gets to like, is that over treating a seven centimeter hernia? And it'