Ascension Via Christi Hernia Center

This reduces complications and increases the durability of the hernia repair. Also, if a complication occurs the patient is more suited to tolerate whatever problem may need to be addressed.

Preoperative optimization is now considered every bit as important as surgical technique in the treatment of complex hernias. Often by the time a patient is referred to a hernia specialist they have had one or more failed attempts at repair. In evaluating many of these patients it is clear that some of the risk factors that would predict a higher risk of complication or hernia recurrence were not fully addressed prior to their original operations.

The key to having a good surgical outcome and a happy patient is getting the patient to be as healthy as they can be before and after the operation. This is essential in the care of all patients especially those with hernias.

Obesity

Target: BMI < 40 for complex laparoscopic or robotic repairs and all open repairs
BMI < 40-45 for noncomplex laparoscopic and robotic repairs

Rationale: There is no doubt that obesity (BMI > 30) is associated with an increased risk of medical and surgical complications in hernia repair. Chief among these are complications in wound healing that can result in a wound infection. These can range in severity from the inconvenience of a small wound infection to a severe problem that will require multiple operations and hospitalizations to correct (1, 2, 3, 4).

Although not shown in every study, much of the evidence available today supports the belief that obesity also contributes to an increased chance that the hernia will come back after repair (5, 6). This is referred to as hernia recurrence. Another repair, which will no doubt be costly and more complex, would be necessary to fix the recurrent hernia.

Complications that are associated with obesity also add to the cost of care for the patient and hospital. We know that reducing a patients weight prior to surgery, along with optimizing other risk factors, significantly decreases the charges for inpatient care, outpatient care, and total hospital charges (7). Another study has demonstrated that patient’s that hit their weight-loss targets incurred lower overall costs (8).

So achieving the goal BMI is better in all respects for the patient. It makes the operation safer, lowers the risk of complication, and costs less for everybody.

Generally speaking, minimally invasive repairs (laparoscopic or robotic surgery) usually are associated with lower risk of wound infection (9). Some patients question the need for weight reduction if a minimally invasive operation is recommended for them. There are three things that need to be kept in mind. First, a minimally invasive repair occasionally needs to be converted to open operation, so we must always plan for this possibility. Secondly, minimally invasive operations are usually longer and require more anesthesia than open operations. The more obese a patient is, the more difficulty they will have in tolerating and recovering from anesthesia. Finally, obesity is associated with other complications irrespective of the operative approach such as blood clots, pneumonia, and heart attacks (10).

Losing weight is not easy and we recognize that. We want to be your partners and will arrange for a nutritionist to work with you if needed and have regular discussions by phone or in person regarding progress. This process can and does work when both the patient and healthcare team are committed (11).

If medical weight loss therapy is not working, we can arrange a referral to discuss weight-loss surgery with a surgeon who specializes in this type of surgery.

Tobacco, Smokeless Tobacco, and Electronic Cigarettes

Target: Complete cessation and abstinence from cigarettes, smokeless tobacco, and electronic cigarette use 30 days prior to scheduled open operation or complex hernias. Recommended for all other operations.

Rationale: Cigarette smoking stands in the way of successful wound healing and significantly increases the risk of a wound infection. Smoking actually decreases the amount of blood and oxygen supplied to the tissues in your body (12, 13, 14). If a wound cannot get oxygen, it cannot heal.

There is a dose dependent relationship between smoking and wound complications and infections and death (15). Said another way, the more a person smokes, the greater the likelihood that they will have a problem healing their surgical wound, to say nothing of the greater chance of dying (15).

Open hernia repairs are especially sensitive to the risks of smoking because of the maneuvers that are required during a hernia operation. Smoking greatly increases risk of a complication from these operations (16, 17, 18).

Cessation of tobacco at least 30 days prior to surgery has been shown to be the minimal time required to decrease this risk (14, 19). During this interval of time nicotine replacement has been used as a bridge to completely quitting and does not appear associated with the same risk of smoking (19).

We will work with you to help you to stop smoking. Often this is the most difficult part of the optimization process and we recognize this fact but the importance of doing so cannot be overstated.

Diabetes

Target: Preoperative Hemoglobin A1C less than 7.0%.

Rationale: The high blood sugars associated with diabetes have long been associated with poor wound healing and a high risk of wound infections. These infections greatly increase the risk of the hernia repair failing and of mesh infection. These complications often require reoperation which will undoubtedly be more complex than the previous operation (20). This additional therapy is not only painful but costly.

In fact, patients with blood sugars greater than 180 (which corresponds to an A1C of greater than 8%) have constantly demonstrated significantly increased risk of infection, need for reoperation, and death (21, 22, 23, 24). The risk of the surgical wound coming apart, referred to as dehiscence, increases with a single episode of glucose greater than 200 after an operation (22).

The goal of preoperative optimization is to correct these glucose levels to a point where the possibility of these painful and costly complications is significantly decreased. Currently, the medical literature suggests that it is best to target a hemoglobin A1C of 6.5-7.5% (23, 24). This level of preoperative sugar control is associated with a decrease in overall infectious complications (23).

The strategy employed by our center first focuses on education and counseling. Working with a nutritionist and your primary care physician we will develop a strategy for control of your diabetes. If necessary, we occasionally refer patients an endocrinologist in order to assist with disease that is especially difficult to control.

Infectious disease

Target: Decrease the degree of infection or wound contamination present at the time of surgery.

Rationale: Much of what has been described in the optimization section so far (weight loss, diabetic control, and tobacco use) focus on decreasing the risk of wound infections. Surgeons will work diligently to limit any contamination of a wound that may lead to wound infection, whether it’s before, during, or after the operation.

Wound infection can occur after nearly any surgical procedure. This complication is especially relevant for the hernia surgeon because wound infections can lead to a chronic mesh infection, one of the most respected complications in hernia surgery (25). While some hernias in particular circumstances may not require mesh placement (mesh and mesh infections are discussed in greater detail in the Mesh section), nearly all complex hernias will require placement of mesh for long-term reenforcement of the hernia repair. Mesh is necessary to provide the best opportunity for a durable and long-lasting repair.

MRSA (methicillin-resistant Staphylococcus aureus) is a bacteria that is resistant to certain types of antibiotics and is especially problematic in hernia surgery. One study has noted that over half of the mesh infections during the study were infected with MRSA (26). Most concerning was that on average, the patient’s with mesh infections required an average of 2.1 additional operations (26).

Previous MRSA infection, regardless of where in the body it is, significantly increases the risk of wound infection within the first 30 days of the hernia operation (27). Previous MRSA infection also means that the hernia operation that needs to be performed will likely be a much more complex procedure (28).

In order to combat this problem, we have implemented a screening program for potential surgical patients (29, 30). Additionally, if a patient has had a previous MRSA infection, lives or works in close proximity to a person known to have MRSA, has been hospitalized in the last 6 months or lives in an institution or care home, or is currently on antibiotics, then they are referred to an infectious disease specialist to assure that the MRSA has been eliminated (31). All fluid collections and open wounds are cultured and treated. This is all in an attempt to decrease the risk of wound infection and to aid in preoperative planning.

Nutrition

Target: Identify patients who are malnourished or undernourished and restore their nutritional status prior to operation.

Rationale: At a given time, approximately 30% of hospitalized patients are undernourished (32). In response to the insult of surgery, the body’s metabolism increases and calls on its nutritional reserves to support recovery (37). If these reserves are depleted, recovery can be compromised. Many studies have confirmed that optimizing a patient’s nutritional status prior to surgery results in a lower rate of surgical complication, length of stay, and need for hospital readmission (33, 34, 35, 36).

Fortunately not all patients require nutritional support prior to an operation. Our goal is to identify those who are at risk and would benefit from nutritional optimization. While several nutritional risk screening tools exist, the nutritional risk screening has been validated in surgical patients and is most commonly used in the elective setting (32).

An immunonutrient is a chemical made by the body that can aid it in the recovery after surgery. Immunonutrition involves providing these substances before and after the operation in the form of specially designed nutritional supplements. This practice can decrease the rate of wound complications, hospital length of stay, and the costs of hospitalization (38, 39, 40, 41). Our practice is to attempt to provide these supplements for at least five days before an operation. Insurance most often will not reimburse for this treatment and patients are often asked to pay for this on their own with a cost between $50 and $150.

Organ system optimization

Target: Identify any preexisting medical problems and optimize each organ system.

Rationale: Every person has a unique medical history and sometimes a prior medical problem, such as a heart attack, can have a significant impact on that person’s ability to tolerate an operation. While risk can never be eliminated completely, much can be done to reduce and manage it. We may ask you to see one or several other doctors prior to your surgery if a previous medical problem is of concern.

As a hernia center, we have these specialists and the resources they require available and ready. Some of the most common reasons for preoperative evaluation in our clinic have been: heart disease, COPD, immune system problems, and patient’s who require anticoagulation.

During these specialty consultations, several things can be accomplished. First, the specialist can usually provide an accurate assessment of the risk of a particular problem affecting the successful outcome of an operation. In the past, these assessments have changed the approach to the planned operation. Secondly, if the problem can be improved or optimized prior to surgery this process can be initiated and directed by the specialist. Third, any additional problems can be identified and treated. Finally, any problems that may occur during or after the operation can be anticipated and a plan of action developed well before the operation.

In this way, we work through every previous diagnosis of a patient’s medical history. Every major organ system is considered and, if possible, optimized.