Hernia: Everything you always wanted to know and more ….

Dana A. Telem MD MPHAssociate Chair for Clinical Affairs

Director, Comprehensive Hernia ProgramAssociate Professor of Surgery

University of Michigan

Why care about hernia?

Common Costly Morbid

Abdominal Wall Hernia

• They are the most common surgical condition encountered by clinicians

• 1.6 million diagnosed annually

• 500, 000 undergo operative repair

• Lifetime risk: 27% for men to 3% for women.

Who needs imaging?

For patients with an appropriate clinical history and physical examination,

imaging is NOT needed.

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What imaging should be performed?

• Although inexpensive and safe, ultrasonography is not very reliable.

• Noncontrast MRI or CT with Valsalva are preferred.

• MRI or CT can also identify other sources of groin pain: ØHip/musculoskeletalØNerve root compressionØRenal calculiØInfection.

Who needs an operation?

• Operative repair is necessary for: • Acutely incarcerated hernias• Hernias causing significant pain or lifestyle limitations

• Watchful waiting considered for:• Patients who are asymptomatic or mildly symptomatic• Frail or medically complex

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Ideal Candidates & Patient counseling points

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Limitations: 1) Predominantly white male patients were included

2) Study participants were also generally healthy,

with ~60% of patients classified as ASA 1

3) Most patients had good access to medical care.

4) Excluded asymptomatic incarcerated hernias.

5) Substantial long-term loss to follow-up.

Groin pain ….• The most difficult and frustrating complication to manage.• Persistent groin pain that lasts for more than 3 to 6 months after

hernia repair.• Occurring in up to 10% to 12% of patients.• Preoperative groin pain is the biggest predictor of postop groin pain.• Hernia related causes:

ØNerve injury/entrapmentØScar tissue formationØReaction to the prosthetic material

Groin pain workup and treatment

• Rule out recurrent hernia or other etiology for pain (CT/MRI)

• Initial management: trial of anti-inflammatory medications and/or local nerve blocks.

• Patients with persistent neuropathic pain may be initially treated with pharmacologic agents (e.g., GABA analogues, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants)

• Operative interventions (neurectomy, nerve stimulator placement, neuroma excision, mesh and suture excision) may be indicated in select patients.

Abdominal wall hernia

What imaging is needed?

• Predominantly a clinical diagnosis.

• CT scan with valsalva is the preferred study.

• Imaging is useful for:• Operative planning for complex hernia• Recurrent hernia*• Patients with a challenging abdominal exam

Who is a candidate for repair?

•RecommendedØIncarcerated/strangulated hernias (acute)ØHernias with high risk features (chronic incarceration)ØSymptomatic hernias causing lifestyle limitations or pain**

Data demonstrate a 12% recurrence rate at 5-years and 23% at 13 years. The risk of recurrence increases with each attempted repair.

Ann Surg. 2003. 237(1):129–135

Arch Surg. 2010;145(4):322-3

Special Considerations

•Patient factors that increase risk of recurrence:ØDiabetes with poor glycemic control*ØObesity*ØSmoking*ØSubstance abuse*ØCollagen disordersØChronic immunosuppressionØWomen of childbearing age

* Modifiable J Am Coll Surg. 2015;221(2):478-85.Hernia. 2014;18(1):19-30.Hernia. 2013;17(5):639-45.

The role of pre-habilitation

• Goal is to optimize patients prior to surgery.

• Modifiable factors:• BMI < 35-40 (surgeon and operation dependent)• Smoking cessation 4-6 weeks preop (cotinine test)• AIC levels < 8

• Data from MSQC suggest adherence would decrease complications and episode of care spending.

Demographic and procedural characteristicsCharacteristic N (%)

BMI Quartile1st 5737 (25%)2nd 5844 (26%)3rd 5703 (25%)4th 5343 (24%)

Nonindependent 224 (1%)HTN 10691 (47%)CHF 57 (<1%)COPD 1874 (8%)CAD 2348 (10%)PVD 450 (2%)Bleeding Disorder 473 (2%)DVT 1124 (6%)OSA 5754 (25%)

Characteristic N (%)Age

<45 5945 (26%)45-64 11191 (49%)>65 5528 (24%)

Female 10496 (46%)Race

White 19252 (85%)Black 2452 (11%)Other 960 (4%)

ASA Classification1 1549 (7%)2 11763 (52%)3 8871 (39%)4 467 (2%)

Characteristic N (%)Alcohol Use 657 (3%)Smoking 5492 (24%)Diabetes Classification

None 18472 (81%)Diet-Controlled 605 (3%)Non-Insulin

Dependent2487 (11%)

Insulin-Dependent 1100 (5%)Open 15868 (70%)Inpatient Status 6974 (31%)

Multilevel mixed-effects logistic regression model of primary outcomes.Increased risk for complication, discharge not to home, ED utilization and 30-day readmission associated with:

•4th quartile obesity (BMI 42)• Insulin Dependent Diabetes• Substance abuse

Added episodes and cumulative spendingAverage Episode Spending Cumulative Episode Spending

Risk Factor Odds Ratio

% with Exposure

AR PARFAdded Spending from Outcome*

Added Spending Attributed to Risk

Factor**

Added Spending from Outcome*

Added Spending Attributed to Risk Factor**

BMIAny Complication 1.64 0.236 0.390 13.1% $9,934 $1,304 $8,990,270 $1,179,707

Serious Complication 1.67 0.236 0.401 13.7% $26,648 $3,638 $11,485,288 $1,568,105

Alcohol UseSerious Complication 1.75 0.029 0.429 2.1% $26,648 $567 $11,485,288 $244,487

Smoking30-Day ED Utilization 1.33 0.242 0.248 7.4% $5,013 $371 $8,990,270 $664,867

Insulin DependenceAny Complication 1.34 0.049 0.254 1.6% $9,934 $163 $8,990,270 $147,323

Serious Complication 1.51 0.049 0.338 2.4% $26,648 $650 $11,485,288 $280,020

Discharge Not to Home 1.49 0.049 0.329 2.3% $16,967 $398 $13,794,171 $323,432

30-Day Readmission 1.68 0.049 0.405 3.2% $18,870 $608 $17,398,140 $561,013

Statewide prehab?

• Expansion of criteria statewide via a hernia carepath

• Focus on glycemic control, obesity and substance cessation

• Creating task force and partnerships

Steps

• Statewide synoptic operative note – select sites Summer 2019.• Iterative refinement and escalation of op note roll out –Fall 2019• Addition of data elements to MSQC for abstraction (January 2020)• Limited site collection (Winter/Spring 2020)• Iterative refinement and escalation (Summer 2020)

Take Home Points

• Imaging is not needed for clinically apparent primary hernias.

• If imaging is considered, MRI or CT with valsalva preferred.

• Watchful waiting for groin hernia is OK for select patients.

• Prehabilitation should be considered prior to hernia repair for high risk patients.

Thank you!dtelem@med.umich.edu

@DanaTelem