Introduction to Hernia Repair
Hernia repair is the most common operation performed worldwide, with over 1 million repairs performed yearly in the United States alone. There are many types of hernias and they can occur at numerous anatomical sites including several different areas of the abdominal wall (umbilical, inguinal, and ventral just to name a few), to areas of the diaphragm, to hernias related to internal anatomy (e.g. internal hernia after gastric bypass surgery).
In addition to anatomic site variation, hernias range from simple first-time occurrences to those that have re-occurred once or several times and thus require a more extensive analysis of why this may have happened and subsequent planning for risk-factor reduction through an individualized plan for subsequent repair.
A hernia is the defect, or hole, through which another structure starts to push through. The hernia is NOT the bulge itself, but rather the gap through which something else is bulging outward or into a space where it does not belong. Hernia meshes are generally similar to mosquito net, but are sterile and more highly engineered to help provide mechanical reinforcement of tissue. Since a hernia is a defect, not an actual structure itself, repairing the hole often requires a patch, or piece of mesh, in order to close the gap and restore the natural integrity of the tissue layers. Sometimes small hernias can be repaired by simply sewing the edges of the hole together, but this only applies to very small hernia defects. For most hernias, a patch is required; experience has shown that repairing a large hernia defect without mesh leads to excessive tension on the tissues, which in turn leads to a guaranteed recurrence of the hernia over time.
Modern Day Hernia Repair is A Complex Algorithm
Hernia repair surgery is one of the most complex and rapidly advancing areas known in Surgery today, and is rapidly becoming a sub-specialty of General surgery, similar to how Vascular, Breast, and Colorectal Surgery have become separate branches of General Surgery because of the level of expertise and multi-disciplinary approach required for good outcomes. Ongoing developments in technology and engineering allow for ever advanced hernia meshes to be created, but this expansion has to be tempered with a solid pedigree in training, extensive knowledge of surgical repair techniques, and an in-depth understanding of the materials science in order to best select a hernia mesh and repair technique for each patient.
Just because a hernia mesh is newly developed or available doesn’t necessarily mean it is the one that should be used in every situation. Contrarily, just because a certain mesh has been used widely in the past doesn’t mean it’s still the best one to use, or the best one to use in that particular patient. Today, there are hundreds of different meshes available on the market, consisting of various synthetic permanent materials, to those derived from biologic tissues, to those created from synthetic compounds that slowly re-absorb into the body over time. In addition, there is variance in the physical construction of the meshes and also numerous anti-adhesive barrier treatments depending on which anatomic location the mesh is to be placed. There are hybrid-weave filaments and even hybrid-biologic meshes available now consisting of a blend of permanent synthetic and biologic material. The variety in selection of meshes for hernia repair is nothing short of mind-boggling, and only a true Hernia Specialist surgeon can best select the repair technique and hernia repair material(s) for a particular patient.
Surgeons who have completed fellowship training in advanced hernia repair techniques, particularly with known experts in the field and who also have an ongoing commitment to keep up-to-date in the hernia repair meshes and how best to use them are considered the Experts in Hernia repair among surgeons today. Being a Hernia specialist requires an intense commitment to ongoing education and the pursuit of excellence. Also, s/he must be committed to optimizing patient outcomes through pre-operative patient education and reduction of risk factors for recurrence, and must also be committed to employing Fast-Track Surgery/Enhanced Recovery (ERAS) Pathways to optimize surgical outcomes. These factors in turn help patients to achieve their best results after hernia repair.
What To Look For In A Hernia Center
Surgeons with fellowship training and demonstrated expertise in Hernia Repair
Hernia repair surgery is a rapidly evolving field; similar to the auto-manufacturing industry, modern-day cars compared to those that were produced 20 years ago have significant advantages in safety and performance. Hernia surgery today is vastly different than what was routinely performed in the 1990s and early 2000s, due to advances in minimally invasive technology, mesh materials engineering, evolution of surgical techniques, and introduction of postoperative recovery protocols. Look for surgeons who have completed fellowship training in complex hernia repair, who have studied and trained with leaders in the field of Hernia Surgery at advanced institutions, and who have published extensively in the literature on hernia repair and hernia repair materials. Comparative studies including those that study the histology and mechanical strength properties of mesh materials confer an in-depth understanding of hernia repair meshes and how best to use them to help patients achieve their best outcomes.
Surgeons who use Fast-Track/ERAS protocols
ERAS, or Enhanced Recovery After Surgery, also called “Fast-Track Surgery” started in the Colorectal literature as a methodology to help patients recover from surgery faster with improved outcomes and less risk of complications. It has taken the surgical world by storm, as more and more surgeons have realized the benefits afforded to patients with less pain, less downtime, faster return to full activity, and fewer days of missed work. The main tenets of Fast-Track Hernia surgery consist of pre-surgery optimization (weight reduction for obesity, smoking cessation, reduction of infectious risks, and physical fitness optimization), reduction in postoperative narcotic pain medication requirements through multi-modal therapy and regional nerve blocks, fluid optimization, early mobilization, and early return to normal diet after surgery.
Surgeons with a history of publications and invited talks
Publications: For a manuscript to be accepted into the published literature, it must first be reviewed by a panel of experts that have been selected to review it. The work is subject to intense scrutiny and may require several rounds of revisions before it achieves final approval for publication or is rejected by the panel. If approved for publication, it is set forward into the literature for others to learn from and refer to in future works of publication, and thus represents a work that embodies the most current evidence to date in the field. In general, the acceptance rate for manuscripts to the published literature is anywhere from 2-40%.
Invited Talks: only the surgeons who are sought-after experts in the field of Hernia Repair are invited to give talks at international meetings. These meetings represent the forefront of modern surgical care, and invited speakers are surgeon experts who are considered to be in the top echelon of thought-leaders in the field and are therefore considered the leading Hernia surgeons in the world.
- Jenkins ED, Melman L, Desai S, Deeken CR, Greco SC, Frisella MM, Matthews BD. Histologic evaluation of absorbable and non-absorbable barrier coated mesh secured to the peritoneum with fibrin sealant in a New Zealand white rabbit model. 2011 Dec;15(6):677-84.
- Jenkins ED, Lerdsirisopon S, Costello KP, Melman L, Greco SC, Frisella MM, Matthews BD, Deeken CR. Laparoscopic fixation of biologic mesh at the hiatus with fibrin or polyethylene glycol sealant in a porcine model. Surg Endosc. 2011 Oct;25(10):3405-13.
- Deeken CR, Melman L, Jenkins ED, Greco SC, Frisella MM, Matthews BD. Histologic and biomechanical evaluation of crosslinked and non-crosslinked biologic meshes in a porcine model of ventral incisional hernia repair. J Am Coll Surg. 2011 May;2012(5):880-8.
- Jenkins ED, Melman L, Deeken CR, Greco SC, Frisella MM, Matthews BD. Biomechanical and histologic evaluation of fenestrated and nonfenestrated biologic mesh in a porcine model of ventral hernia repair. J Am Coll Surg. 2011 Mar;212(3):327-39.
- Melman L, Jenkins ED, Hamilton NA, Bender LC, Brodt MD, Deeken CR, Greco SC, Frisella MM, Matthews BD. Histologic and biomechanical evaluation of a novel macroporous polytetrafluoroethylene knit mesh compared to lightweight and heavyweight polypropylene mesh in a porcine model of ventral hernia repair. 2011 Aug;15(4):423-31.
- Melman L, Jenkins ED, Hamilton NA, Bender LC, Brodt MD, Deeken CR, Greco SC, Frisella MM, Matthews BD. Early biocompatibility of crosslinked and non-crosslinked biologic meshes in a porcine model of ventral hernia repair. 2011 Aug;15(2):157-64.
- Brown SR, Melman L, Jenkins E, Deeken C, Frisella MM, Brunt LM, Eagon JC, Matthews BD. Collagen type I:III ratio of the gastroesophageal junction in patients with paraesophageal hernias. Surg Endosc. 2011 May;25(5)1390-4.
- Melman L, Jenkins ED, Deeken CR, Brodt MD, Brown SR, Brunt LM, Eagon JC, Frisella M, Matthews BD. Evaluation of acute fixation strength for mechanical tacking devices and fibrin sealant versus polypropylene suture for laparoscopic ventral hernia repair. Surg Innov. 2010 Dec;17(4):285-90.
- Jenkins ED, Melman L, Desai S, Brown SR, Frisella MM, Deeken CR, Matthews BD. Evaluation of intraperitoneal placement of absorbable and nonabsorbable barrier coated mesh secured with fibrin sealant in a New Zealand white rabbit model. Surg Endosc. 2011 Feb;25(2):604-12.
- Jenkins ED, Melman L, Deeken CR, Greco SC, Frisella MM, Matthews BD. Evaluation of fenestrated and non-fenestrated biologic grafts in a porcine model of mature ventral incisional hernia repair. 2010 Dec;14(6):599-610.
- Jenkins ED, Melman L, Frisella MM, Deeken CR, Matthews BD. Evaluation of acute fixation strength of absorbable and nonabsorbable barrier coated mesh secured with fibrin sealant. 2010 Oct;14(5):505-9.
- Jenkins ED, Yom V, Melman L, Brunt LM, Eagon JC, Frisella MM, Matthews BD. Prospective evaluation of adhesion characteristics to intraperitoneal mesh and adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair. Surg Endosc. 2010 Dec;24(12)3002-7.
- Jenkins ED, Yip M, Melman L, Frisella MM, Matthews BD. Informed consent: cultural and religious issues associated with the use of allogenic and xenogenic mesh products. J Am Coll Surg 2010 Apr;210(4):402-10.
- Jenkins ED, Yom VH, Melman L, Pierce RA, Schuessler RB, Frisella MM, Christopher Eagon J, Michael Brunt L, Matthews BD. Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study. Surg Endosc 2010 Aug;24(8):1872-7.
- Melman L, Chisholm PR, Curci JA, Arif B, Pierce R, Jenkins ED, Brunt LM, Eagon C, Frisella M, Miller K, Matthews BD. Differential regulation of MMP-2 in the gastrohepatic ligament of the gastroesophageal junction. Surg Endosc 2010 Jul;24(7):1562-5.
- Curci JA, Melman LM, Thompson RW, Soper NJ, Matthews BD. Elastic fiber depletion in the supporting ligaments of the gastroesophageal junction: a structural basis for the development of hiatal hernia. J Am Coll Surg, Aug 2008; 207(2):191-6.
- Melman Lora, Matthews Brent. Chapter 26: The Washington Manual of Surgery, 6th edition. Lippincott Williams & Wilkins. Philadelphia, PA 2012