Dr. Mike (Host):
Welcome to MD Cast by Tampa General Hospital, a go-to listening location
for specialized physician-to-physician content, and a valuable learning
tool for world-class Healthcare.
I'm Dr.
Mike.
And with me today is Dr.
Monica Polcz from Tampa General Hospital.
She's an Assistant Professor of Surgery at USF Health Morsani College of Medicine.
And today, we're talking about innovations in ventral hernia care.
Dr.
Polcz, welcome to the show.
Monica Polcz, MD: Hi, Dr.
Mike.
Thanks so much for having me.
It's a pleasure to be here and talk a little bit about
what I love, which is hernias.
Host: That's great.
That's great.
How about a quick review.
Let's have a nice review of ventral hernia, what are some of the major risk
factors, and how do patients typically present, you know, those symptoms.
Monica Polcz, MD: Yeah.
So, ventral hernias are overall on the rise.
So, we're doing about 600,000 repairs every year in the United States, and
that rate has almost doubled when you compare to the decade prior.
And what a hernia is, it's essentially a hole through the
muscles in the abdominal wall.
They don't always cause symptoms, but many times they can lead to pain,
some core weakness or instability, and even emergencies like a bowel
obstruction if the bowel gets trapped in that hole or the hernia.
Hernias can be present from birth or they can develop over time, so
things like previous incisions, pregnancy, obesity, heavy physical
stress can all weaken the tissues of the abdominal wall and predispose
patients to developing a hernia.
And unfortunately, some of the same factors that predispose patients to
developing hernias, especially after abdominal surgery, things like obesity,
smoking, diabetes, wound complications.
These things all also increase the chances of a failed repair.
And a failed repair really matters, because every recurrence
portends a sequentially higher risk of future recurrence.
So, there was a study published in the Journal of American College of
Surgeons that demonstrated that by the time you're fixing a hernia for
the third time, there's a nine times higher odds of that hernia recurring.
And recurrent hernias are generally more painful, and
they're more challenging to repair.
And then, other complications of hernia repairs, things like mesh
infections, which can be truly devastating and life-altering, are
often preventable in many cases.
And so, in my mind, this is why it's really so important to set ourselves
up for success the first time around.
Host: Why do you think we're seeing more cases?
Monica Polcz, MD: I think we're doing more surgeries, and the risk
factors for developing a hernia are becoming more and more common.
So, again, things like obesity, diabetes, these are all diseases
that are becoming more common.
The other thing I think we're doing a better job of is we're starting to
follow up our patients better long term.
And we're realizing that even our own recurrence rates after hernia repairs are
much higher than we previously thought.
And that's another really important point.
I mean, if we aren't following and tracking our outcomes, we'll
never know how we can do better.
And we used to think a hernia was just a hole.
Like how hard can it be to fix?
And now, we have entire societies, registries, and even conferences
that are dedicated to improving hernia care all around the world.
And fellowship training is becoming more formalized in the
United States and in Europe.
There's even now separate board certification for abdominal wall surgery.
And the science behind hernia is also really just rapidly growing.
If you look at the number of publications related to ventral hernia in the
past few decades, there's really an exponential growth in the amount
of research that's being published.
You just type in ventral hernia into PubMed, and you can see
truly exponential growth.
So, we're in the midst of a shift in focus nationwide and worldwide, really
towards improving the quality of care that we're providing to these patients
and the types of surgeries that we offer.
Host: Speaking of the surgeries and the types of surgeries, what are some of
the biggest shifts that you've noticed in hernia care over the past decade?
Monica Polcz, MD: Yeah.
So, I think a really important one to talk about is regionalization.
And this is a trend that's happening across surgery.
So, cancer care, transplant, and now even hernia, we're seeing that
high-volume centers with multidisciplinary teams tend to have better outcomes.
and this seems to hold true for complex hernia as well.
And that doesn't necessarily mean every patient needs a hernia center.
Most hernias can and should be handled by skilled surgeons close to home.
But for complex cases, so very large hernias, recurrences, or patients with
serious medical issues, referral to these specialized centers like we have
here at USF and Tampa General Hospital can really make a big difference.
So, the literature supports that, in these centers, outcomes can even be
comparable to primary initial hernias.
So, we talked previously about how every recurrent hernia portends a
sequentially higher risk of recurrence.
But at these tertiary centers, often the outcomes are equivalent
to primary initial hernia repairs.
And why is this the case?
It's not just surgeon experience, although certainly that's very important.
I think these centers have a unique infrastructure, so there's coordinated
preoperative optimization, specialized nursing care and collaboration with other
services like bariatrics, geriatrics, plastics, infectious disease, physical
therapy, radiology, anesthesia, and they all play a part in this success.
Host: When should a general surgeon in, let's say, a smaller town, a city that
doesn't have a tertiary care center like you work at, when should they really
think about referring a patient to you?
Monica Polcz, MD: Absolutely.
So, I think patients, again, who are more complex and that can be
difficult to define, even things like severe medical comorbidities,
patients with organ failure.
We have transplant teams here, patients who may need a higher level
of care after surgery with very large hernias who may encounter things like
respiratory failure after surgery and need specialized ICU care.
Those are certainly patients that are worth the consideration of referring to
a more specialized center or patients again who have had several failed repairs
are at baseline going to be at higher risk of having subsequent failed repairs.
Those are certainly patients that I would consider referring our patients
with just complex, large hernias.
Host: Looking at the surgical treatment, what advances have we seen in surgical
techniques or even tools that are really helping to improve outcomes
and lower the complication rates?
Monica Polcz, MD: Yeah.
So, the technical side of the operations that we're performing
have really grown dramatically.
So, robotic approaches now allow us to repair many even very large hernias with
smaller incisions, less pain, faster recovery, fewer wound complications.
Sometimes with very large hernias, the challenge is getting the muscles closed.
And if we can't get the muscles completely closed, the recurrence
risk goes up more than sevenfold.
And so traditionally, we would do something called a component separation,
which involves dividing one of the abdominal wall muscle layers to
gain length and to gain some laxity to get the abdominal wall closed.
And it works well.
It can even be done robotically.
But these procedures should really be performed by a surgeon who does
a high volume of these procedures, because the anatomy can certainly be
confusing and, if they're not performed correctly, can lead to even larger
hernias that destabilize the abdominal wall and are very challenging to treat.
And a component separation is a useful tool.
It's often the best option for many patients.
But even in experienced hands, these procedures are not risk-free, they
double the wound complication risk.
So, we even have now alternative strategies to sometimes avoid a component
separation even with very large hernias.
So, one example would be BOTOXinjections into the abdominal muscles.
This is done about four to six weeks before surgery and is a much less
invasive way to relax the abdominal wall.
And the effect is temporary, lasts about three months.
And it allows for easier closure of the abdominal wall without cutting muscle.
And so, published data with BOTOXshows higher rates of successful fascial
closure, lower recurrence and, compared to component separation
techniques, lower wound complications.
And, again, unlike a component separation, the effect is temporary.
And then, we have other options.
So now, we do totally preperitoneal repairs, which gives us some similar
benefits to component separations in that we can place a larger mesh for
larger hernias, but spares the muscle.
And so, that can also be done robotically or open.
So really, we have several different techniques, several
tools in the toolbox, so to speak.
Host: Yeah.
But when are these decisions made?
Is this something that you try to lay out preoperatively, or is this
something you're having to make a decision when you're in surgery?
Monica Polcz, MD: I think planning is key.
Setting yourself up for success is also key.
I think it's important to go into the operating room with several
tools, and plan A, B, and C.
And certainly, I go in with a plan, but sometimes that plan changes depending
on the intraoperative findings.
But the more we prepare and the more we sort of set ourselves up for success and
optimize patients, the better we can plan and predict how the operation will go.
Host: Is there anything in the future, some research going on that
you're interested in that you think is going to have a major impact
on surgical repair of hernias?
Monica Polcz, MD: Yeah.
So, one of my major research interests is actually clinical
outcomes type of research.
And the hernia literature overall is lacking in that, historically, and
currently our follow-up is very poor.
So, for example, there was one large study that was recently published in
a high impact journal that used one of our national hernia registries and
had some pretty depressing numbers.
So, they estimated that the recurrence risk over five years after ventral
hernia repair with mesh was as high as 40% and as high as 70% without mesh.
But when you actually look at the follow-up rate in that very large study
published in a very high-impact journal, the median follow-up was only 29 days.
So, that means that less than 50% of patients had even a month of follow-up.
And we know, anyone who fixes hernias know, that recurrences
don't happen generally in the first few days or weeks after surgery.
They can happen even years after a repair.
And when you were looking at the rate of follow up at five years,
which is the timeframe in which this paper estimated recurrence,
the follow-up rate was less than 1%.
It was 0.5%
of patients actually had five-year follow-up.
And so, how can you accurately predict the risk of recurrence when
the followup is absolutely terrible?
So, I think that the most important thing we can do Is
improve our follow-up of patients.
I like to see my patients every year after surgery and really keep following them
so we know how they're actually doing, and then we can continue to get better.
Once we have our own results, we can continue to improve.
Host: How do some of the modifiable risk factors affect this?
So if you have somebody maybe with obesity, smoke or what have you, they
get the surgery and they're not really making strides in that risk factor?
Is that playing a role too in recurrence?
Monica Polcz, MD: Yeah.
So, there's a few things when we're thinking about optimizing modifiable
risk factors before surgery.
And I'll start with one example that you mentioned, which is obesity.
So, obesity raises hernia risk in two ways.
It puts more mechanical strain on the abdominal wall and also increases the
risk of wound complications after surgery.
And both of those things independently also drive recurrence.
We know that wound complications lead to recurrence, so anything
that increases the risk of wound complications, obesity, smoking will
thereby increase your risk of recurrence.
So before surgery, we may talk with patients about
things like weight management.
And this is often difficult for them because many patients feel
limited in their activity due to the symptoms from the hernia.
And so, often just saying increase your exercise to lose
weight is not realistic for them.
And so, sometimes we talk about things like diet.
Sometimes it's bariatric medicine or surgery.
I think the most important thing is that we don't just say, "Come
back when you've lost weight."
We follow these patients very closely.
We're seeing them every couple of months, reassessing their symptoms,
assessing their progress, and continually discussing the best timing of surgery.
And the same goes for other risks.
So, we connect patients with tobacco cessation programs.
We help tighten their blood sugar control.
We build their strength or nutrition preoperatively.
We have heart failure and transplant teams that can weigh in on patients
who may be considered too high risk for surgery elsewhere and
help optimize those comorbidities.
And so, with the right preparation, we can really break the cycle of
complications and recurrences.
And again, in many cases, this preparation is just as important
as the operation itself.
Host: Talking about recovery, given the fact that like you mentioned, we
need more follow-up time, modifiable risk factors have to be dealt with.
But overall, what is kind of your ideal recovery regimen for patients?
Monica Polcz, MD: Yeah.
So depending on the extent of the surgery and the type of surgery, some patients
are discharged home the same day.
Other patients are in the hospital for a few days after surgery.
My goal is that patients are up and moving around right away after the surgery.
I talk to them about things like avoiding heavy lifting or straining their abdomen
for six weeks or so while things heal.
But in general, most patients are up and moving around and back to basic
daily activities almost immediately.
I see patients a couple of weeks after surgery, one in three months after
surgery, and then every year thereafter.
And again, I don't like to just operate on them and say, "Call me if you need me."
I like to really be involved and available if they have any
concerns and establish a long-term relationship, because we're starting
to understand that hernia is sometimes more of almost a chronic disease.
And these patients do need to be followed up longer than just a month.
Host: I agree with that.
And it sounds like you have a very detailed approach to recovery.
Lastly, what's the key takeaway that you would like physicians to know about
long-term success after hernia repair?
Monica Polcz, MD: The key takeaway I think from all of this is that hernias
are becoming more common and more complex.
The recurrences are probably higher than we historically thought,
but we need to get much better at following up our patients.
But our tools are also, honestly, better than ever.
I think success depends on more than just surgical skill, thoughtful timing,
optimizing patients beforehand, tailoring the technique, these are all important.
And for straightforward hernias, I think most general surgeons do excellent work.
And those surgeries should be performed close to home where the patient can
recover in their own environment.
But for complex, recurrent, or medically fragile patients, I would
consider referral to a tertiary center for a multidisciplinary approach.
And with the right preparation and the right team, we can give patients
the best chance at a durable repair and a better quality of life.
Host: Dr.
Polcz, this was fantastic information.
Thank you so much for coming on the show today.
Monica Polcz, MD: Absolutely.
I appreciate your time, and I appreciate you having me.
Host: For more detailed information and to collect your CME, please
click on the link in the description.
For additional CME opportunities, including live webinars, on-demand videos,
and local events offered by Tampa General Hospital, you can visit cme.tgh.org.
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This is MD Cast.
I'm Dr.
Mike.
Thanks for listening.