OPEN SUBJECT ?Constantly evolving techniques and products make it impossible for anyone to know everything there is to know about hernia repair.

The biggest advance in hernia repair in recent years has been the growing awareness that there's no one-size-fits-all best technique. There's no best mesh, no best fixation and no best approach to managing pain. On the surface, that might sound discouraging, but it shouldn't. When we accept the realization that biologic complexity and biologic variability make uniform solutions impossible, we take a big step toward better outcomes.

Everything in hernia repair is constantly evolving. What we thought was the right answer 10 years ago we now realize may be right for some patients, but definitely isn't right for everybody. Meanwhile, every year brings new ideas, new products and changes in old products. We can try to keep up through training and education, but it isn't realistic to expect anyone to know all the techniques, all the available mesh options and so forth. My focus is on hernia disease but I'm not perfect. The only way I can get better is to listen to patients, collaborate with other committed surgeons and keep learning.

In short, we need to adopt a systems approach. We need to collect and share data, so we can better understand and define the sub-populations who don't respond the way other patients do — patients who will be better served or possibly harmed by a given technique or a given mesh.

Focus on value
Hernia repair is a balancing act. A patient with a recurrent hernia is likely to be more challenging and more likely to have problems. You can virtually guarantee no recurrence by using a huge mesh and lots of fixation, but if you do, there's a good chance you'll be trading low recurrence for an increase in chronic pain. Conversely, you can use a smaller mesh and reduce the amount of fixation to minimize pain, but that could lead to a higher recurrence rate. In other words, if you focus on one goal, you tend to lose sight of other goals.

Instead, we should be focused on total value, which encompasses all of the pertinent goals in hernia surgery:

• cost,
• quality measures (recurrence rate, acute and chronic pain),
• quality of life (return to activities), and
• patient satisfaction.

We have a better chance of achieving high value when we look at all of those goals together than we do if we look at them individually. To do that, we need to collect data through the entire cycle of care and determine what factors in the process matter. As you collect data, you learn from it. Over time, analytics can help you identify patterns related to sub-populations.

There may, for example, be patient factors, such as BMI or medicines patients are taking. There may be environmental factors: Was the repair done in an outpatient setting or inpatient setting? What techniques were used? Mesh plays a role for some sub-populations.

The local environment, which includes the surgeon's training, education and other preferences, is also a factor. If I'm going to be operating on a healthy 40-year-old male with no significant comorbidities, I'd suggest either a laparoscopic approach, and discuss a variety of mesh options, or — if they don't want mesh in their body — an open approach with no mesh and a tissue repair. An important point here: Patients are increasingly driving the mesh issue. Patients are online and they're coming in with concerns, because they've read about mesh lawsuits and mesh complications.

Other surgeons might offer an open mesh repair or just a laparoscopic repair, because that's what they do most commonly. The "right" approach, even for a relatively straightforward patient, can vary according to local environments.

PROBLEM OR NOT? For a sub-population of patients, mesh can contribute to chronic severe pain. One goal is to be able to identify those patients ahead of time.

Square pegs
One reason open inguinal hernia surgery with mesh has become such a common procedure it that it's relatively easy to teach and learn. And it works very well on a lot of patients. But unfortunately, there's a subset of people who have severe chronic pain after open inguinal procedures with mesh. And that group is both growing and having a major impact on hernia repair. Every year somewhere between 10,000 and 15,000 patients experience that severe chronic pain.

The question becomes, what can be done differently for those patients? Would a laparoscopic approach be better? Should you use mesh, and if so, what type? There are a lot of different options out there. Multiple factors contribute to success or lack of success.

Some of those patients might do better with other techniques, but the more traditional open non-mesh procedures are a lot more complex to teach. The laparoscopic approach is also very difficult to teach and learn. The groin is a very complex area and it's difficult to learn the whole 3-dimensional anatomy of it. There's definitely a barrier in terms of the learning curve.

Learn and share
We can continue learning at society meetings, courses and online offerings. And you can learn if you happen to be in a venue where there are other surgeons and experts. But again, there is — or should be — a growing realization that we should all be collecting our own data and our own outcomes, and using that data to help inform both patients and our peers about opportunities for improvement. There are a growing number of ways to do that. The American College of Surgeons was one of the first, with the National Surgical Quality Improvement Program (site.acsnsqip.org). There's also the American Hernia Society Quality Collaborative (ahsqc.org). My company, Surgical Momentum (surgicalmomentuminc.com), also provides quality improvement and patient safety services.

We need to be looking at things from the standpoint of how we can improve — perioperative pain management, pre-op preparation, weight loss, smoking cessation, nutrition. What are the things that give us the opportunity to have the best possible outcome?

Breakthroughs in pain
One of the biggest recent advances involves a couple of options for long-acting local anesthetics. There are pain pumps that allow you to implant a catheter and have local anesthetic delivered to the repair site over a period of a few days. There are also long-acting local anesthetics that get released over time. Those options work really, really well in some people, but not in everybody. What goes wrong? Sometimes it's injection techniques. Sometimes it's catheter placement. Sometimes there are patient factors. It might also be that a given surgery turned out to be more extensive than expected and involved other nerves outside of the anesthetized area.

In our practice, we now have some patients who wake up with no pain, who are able to get up and move around, and who never take pain medications. That's a big advance for hernia repair and one that represents a fairly recent advancement in thinking. We always used to assume surgery was going to cause pain and that you just had to manage it with pain meds, at least for a few days. We also assumed that it was going to take a few weeks to get back to activities. Now there's reason to think we can keep shortening that timeline by using multimodal pain management and by collecting and mining data in a way that fosters continuous improvement.

Shifting attitudes
Ultimately, the improvements we're striving for are about letting go of the trained belief that we, as surgeons, have to know all the answers — that everything having to do with patient outcomes is dictated by our skill and our skill alone. We need to open our minds, focus on value-based outcomes and realize there are many, many other factors. We need to team up with patients and with others who can add value. It's going to take a change in some people's mindsets, but it's necessary if we're going to improve our healthcare system.

Will there be resistance? Sure, but only from those who don't yet understand. We can't ignore the fact that we can't keep up with all the information that's out there, that we can't know what's right for every single patient. It's just not realistic. Gradually, more and more surgeons are realizing that. I'm seeing it at meetings and in the work that our company does. More and more surgeons understand that we all need to collaborate and learn from each other.