Dear Editor:
We read with interest the article by Dr. Jason David et al. in the November edition, titled "Failure of Follow-Up: Scrotal Hernia Case Illustrates Healthcare Disparities." We commend the authors for highlighting this unusual case and emphasizing the need for interdisciplinary management in patients who face healthcare disparities. We would like to address the proposed surgical treatment and estimated costs, with insight from the surgeon’s perspective.
A large hernia (>10 cm width) with loss of domain (LOD) is categorically a “complex abdominal hernia.” Treatment considerations differ substantially when comparing a simple hernia to those with extensive LOD. LOD can generally be understood to describe the significantly abnormal relationship between a hernia sac and the existing abdominopelvic volume.1 Different sources have expressed the concept of LOD as a ratio of hernia sac volume to abdominal cavity volume or total peritoneal volume. Some surgeons use a cutoff value of 20%, while other authors use up to 30%. It serves as a predictor of operative difficulty and success.2 This case was a large, though patent, hernia containing several loops of bowel with significant LOD.
Treatment is not simple. In returning the hernia contents to the abdominopelvic cavity and restoring the integrity of the abdominal wall, surgical treatment must be highly individualized and carefully planned. A complex abdominal wall reconstruction (CAWR), consisting often of an abdominal component separation combined with placement of mesh, is typically warranted. This often requires collaboration between general surgery and plastics/reconstructive teams; additionally, postoperative care may require an experienced ICU.3 The surgical resources for complex mesh repairs are not available at all hospitals.
Potential complications are significant. Our colleagues rightfully bring up the well-known complications of general hernia intervention, including poor wound healing and hernia recurrence. With complex LOD hernias requiring abdominal wall reconstruction, the adverse sequalae can be substantially life-threatening. Reduction of hernia contents into the peritoneal cavity can lead to an abrupt increase in intra-abdominal pressure, reduction of venous return, and decreased diaphragmatic excursion. Reduction in tidal volume, postoperative ileus, and abdominal compartment syndrome are potential postoperative complications. Intensive management is essential, including bladder pressure monitoring, serial abdominal examinations, and consideration of elective mechanical ventilation to monitor peak airway pressure.1 The overall morbidity and mortality of an elective CAWR can range as high as 66% and 6.7% respectively.4
These complications become more prominent with underlying comorbidities. This patient had several conditions that compromised his ability to heal and served as a positive predictor of morbidity and mortality for CAWR:5 untreated Hepatitis C, HIV, poor nutrition, IVDU, and untreated psychiatric illness.
Arguably, the most important preoperative consideration for patients who present for urgent evaluation of a hernia is the delineation of elective vs emergent/urgent categorization. It is imperative that complicated hernias be repaired in the elective setting if feasible, as the morbidity and mortality rise with emergent interventions. Prospective studies have shown that the risk for 30-day mortality, reoperation, and readmission increased up to 15-fold after emergency repairs rather than elective repairs. Mesh repair is widely accepted as superior to tissue repair in large hernias as the recurrence rate decreases by 50%-75%.6 In comparison to elective surgery, the option of using mesh is less likely in emergency surgery. Bowel resections are significantly more common in emergency hernia operations compared to elective repair.7,8 This patient’s hernia was widely patent, and he had no clinical or laboratory abnormalities to suggest bowel compromise or systemic signs of sepsis. Given this patient had no indication for emergent surgery and the aforementioned factors made him a poor surgical candidate, the safest course of action was treatment of medical comorbidities and repair of his hernia in the elective setting.
The overall predicted costs for surgical intervention for hernias with LOD range between $24,000-$64,000. Increased hospital length of stay, ICU admission, preoperative testing, and treatment of any complications with possible need for reoperation can add $54,000-$100,000+.8,9 Postoperative reconditioning must also be factored, as frail patients may require physical rehabilitation services to maximize mobility after a CAWR. These expenses represent a major barrier to a patient who is uninsured or underinsured.
Our EM colleagues rightfully bring up concerns that extend beyond this case; namely, the growing use of the ED as the sole source of primary care. The social determinants of health often play a major role in precluding patients from obtaining outpatient surgical evaluation. Delay in management can progress disease from elective to urgent or emergent in nature - while emergency hernia repair typically leads to higher costs and worse outcomes.
We agree that a continuous series of ED visits for chronic, non-emergent surgical illness is not productive for the patient. It is only through the interdisciplinary effort of surgery, social work, primary care, and patients themselves that barriers can be overcome, and meaningful progress made in delivering elective surgery.
Sincerely,
Gabriela M. Doyle, MD
Surgery Resident
University of Nevada, Las Vegas School of Medicine
@surgeon_and_tonic
Taylor Fontenot, MD
Surgery Resident
University of Nevada, Las Vegas School of Medicine
@tfontenotmd
References
- Parker SG, Halligan S, Blackburn S, et al. What Exactly is Meant by “Loss of Domain” for Ventral Hernia? Systematic Review of Definitions. World J Surg. 2019;43(2):396-404. doi:10.1007/s00268-018-4783-7
- Passot G, Villeneuve L, Sabbagh C, et al. Definition of giant ventral hernias: Development of standardization through a practice survey. Int J Surg Lond Engl. 2016;28:136-140. doi:10.1016/j.ijsu.2016.01.097
- Bougard H, Coolen D, de Beer R, et al. HIG (SA) Guidelines for the Management of Ventral Hernias. :29.
- Russello D, Sofia M, Conti P, et al. A retrospective, Italian multicenter study of complex abdominal wall defect repair with a Permacol biological mesh. Sci Rep. 2020;10(1):3367. doi:10.1038/s41598-020-60019-0
- Joseph WJ, Chow I, Baron ME, Beers EH. Abstract: Frailty Predicts Morbidity, Complications, and Mortality in Patients Undergoing Complex Abdominal Wall Reconstruction. Plast Reconstr Surg Glob Open. 2018;6(9 Suppl). doi:10.1097/01.GOX.0000547135.15546.29
- SCORE | Chapter 44. Hernias. Accessed March 22, 2021. https://www.surgicalcore.org/chapter/418595#418626
- Helgstrand F, Rosenberg J, Kehlet H, Bisgaard T. Outcomes after emergency versus elective ventral hernia repair: a prospective nationwide study. World J Surg. 2013;37(10):2273-2279. doi:10.1007/s00268-013-2123-5
- Fischer JP, Basta MN, Mirzabeigi MN, et al. A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases. Ann Surg. 2016;263(5):1010-1017. doi:10.1097/SLA.0000000000001394
- Fischer JP, Wes AM, Wink JD, et al. Analysis of perioperative factors associated with increased cost following abdominal wall reconstruction (AWR). Hernia. 2014;18(5):617-624. doi:10.1007/s10029-014-1276-y