Finding "the best" hernia repair surgeon

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mimelim

mimelim

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Background: I have a family friend with large bilateral inguinal hernias. His father suffered a similar predicament and ended up with 5 hernia repairs before ending up dying from CRC with a recurrent hernia on one side. In short, his father suffered extensively from his hernias despite going to what I would consider well trained, high volume surgeons in a major city. He has a brother with a history of hernias as well. My family friend has considerable wealth, resources and resolve to find "the best" hernia surgeon in the world to operate on him and minimize his risk of complications/recurrences. He is of the opinion that his family history makes him a higher risk of recurrence than others, which I am inclined to agree with from my limited reading and experience. Now he is searching both inside the US and out for a hernia surgeon.

Assuming cost is no object, how would you find "the best" surgeon?

What would be your search criteria?

I know there are dedicated hernia factories out there. How would you compare them?

The reality check: Is the difference between the "best" in the world and the "best" in a particular metropolitan area actually significant?



ps. These questions are being posed to GS faculty at my institution, but I figured I'd get some decent thoughts on here from a somewhat younger crowd :).
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mimelim said:
Background: I have a family friend with large bilateral inguinal hernias. His father suffered a similar predicament and ended up with 5 hernia repairs before ending up dying from CRC with a recurrent hernia on one side. In short, his father suffered extensively from his hernias despite going to what I would consider well trained, high volume surgeons in a major city. He has a brother with a history of hernias as well. My family friend has considerable wealth, resources and resolve to find "the best" hernia surgeon in the world to operate on him and minimize his risk of complications/recurrences. He is of the opinion that his family history makes him a higher risk of recurrence than others, which I am inclined to agree with from my limited reading and experience. Now he is searching both inside the US and out for a hernia surgeon.

Assuming cost is no object, how would you find "the best" surgeon?

What would be your search criteria?

I know there are dedicated hernia factories out there. How would you compare them?

The reality check: Is the difference between the "best" in the world and the "best" in a particular metropolitan area actually significant?



ps. These questions are being posed to GS faculty at my institution, but I figured I'd get some decent thoughts on here from a somewhat younger crowd :).
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I'm not sure there would be a significant difference between the best in the world and the best in your town. As you know, Inguinal hernia repair is one of the simpler operations we perform. I would just find someone who is high volume. I'm not sure his family history of inguinal hernias affects things too much.

Since it's bilateral, he may benefit from a TEP, so finding surgeons with a high volume TEP practice may be the best approach.
 
Agree (as usual) with SLUser.

1) there is generally a finite limit to being "great"; you don't have to travel the world to find someone who is a great hernia surgeon

2) hernia repairs aren't as simple as we generally make them out to be

3) recurrences are common

4) family history is likely unrelated unless this friend has Ehler Danlos or other CVD, is elderly or mobidly obese
 
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Winged Scapula said:
Agree (as usual) with SLUser.

1) there is generally a finite limit to being "great"; you don't have to travel the world to find someone who is a great hernia surgeon

2) hernia repairs aren't as simple as we generally make them out to be

3) recurrences are common

4) family history is likely unrelated unless this friend has Ehler Danlos or other CVD, is elderly or mobidly obese
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I keep putting 'the best' in quotes because it feels wierd to say. I've done a dozen or so inguinal hernia repairs, half of them doing the majority of the operation as an intern. I appreciate the concept of going to a high volume center. The question is, "is going to somewhere like Shouldice substantially better than your local surgeon?"


As for hertability, I am extrapolating from the vascular world. With AAAs, we assume that there is a collegen disorder at play, regardless of a diagnosis or not. We simply can't test for the majority of collegen/connective tissue disorders, but we do know that tissues simply tend to be weaker and more pliable. Am I wrong to consider that abdominal walk weakness is any different? Certainly not provable, but I don't think it is crazy to think that families with strong predisposition are going to possibly have a higher rate of recurrence.
 
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Unless your family friend lives in a very underserved area, there should be someone in his community that does good work.

I have a major problem with patients who go out of town for "the best" surgeon for a relatively common problem. They frequently don't have good plans for follow up care and suddenly they're looking for someone local who can see them.

I've been on the receiving end of "Mr VIP" who wanted "the best" and went out of town to Mayo/MD Anderson/Hopkins/HSS for relatively routine surgery. And then, when "Mr VIP" came home to the Midwest and had a complication of some sort, I was suddenly the local All-Star. Guess what my answer was? "I'm not your doctor. I did not do this operation. You need to return to the original operating surgeon for post-op care regarding this complication."

There are always those few super-high-end things that need to be done by "Legendary Dr X" -- but a hernia isn't one of them.
 
maxheadroom said:
rk.

I have a major problem with patients who go out of town for "the best" surgeon for a relatively common problem. They frequently don't have good plans for follow up care and suddenly they're looking for someone local who can see them.
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Does that include when I wanted you to do my carpal tunnel release? ;)
 
maxheadroom said:
There are always those few super-high-end things that need to be done by "Legendary Dr X" -- but a hernia isn't one of them.
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Winged Scapula, can I change my online name to "Legendary Dr X" please?
 
Nah...I would just fly back and see you (or stick Rimma with your problem). :D

You still got another chance… The ganglion at the base of my middle finger is getting bigger every day.
 
maxheadroom said:
Most hand surgeons would choose serial aspiration for a looooooong time before having a dorsal ganglion excised.
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TOTALLY.

I have no intention of having it excised. Its actually volar at the MCP crease rather than the classic dorsal. I tried aspirating it myself but it huuuuuuurrrrtttt! :laugh:
 
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You're tough to try that. Volar ones along the tendon sheath can be a bit trickier to aspirate/rupture. They tend to be very mobile and will jump away from the needle.
 
maxheadroom said:
You're tough to try that. Volar ones along the tendon sheath can be a bit trickier to aspirate/rupture. They tend to be very mobile and will jump away from the needle.
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Yeah. Its gotten to 1 cm in size and I was playing with it one day in the OR and figured "WTH, I'll try and aspirate it".

For some reason, because I was able to stick myself in the thigh with a 31 Ga of Imitrex I thought the hand wouldn't be much more difficult. The mobility wasn't a problem; it was that the hands a mite more sensitive. :laugh:
 
maxheadroom said:
I have a major problem with patients who go out of town for "the best" surgeon for a relatively common problem. They frequently don't have good plans for follow up care and suddenly they're looking for someone local who can see them.

I've been on the receiving end of "Mr VIP" who wanted "the best" and went out of town to Mayo/MD Anderson/Hopkins/HSS for relatively routine surgery. And then, when "Mr VIP" came home to the Midwest and had a complication of some sort, I was suddenly the local All-Star. Guess what my answer was? "I'm not your doctor. I did not do this operation. You need to return to the original operating surgeon for post-op care regarding this complication."
.
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:thumbup:
 
maxheadroom said:
I've been on the receiving end of "Mr VIP" who wanted "the best" and went out of town to Mayo/MD Anderson/Hopkins/HSS for relatively routine surgery. And then, when "Mr VIP" came home to the Midwest and had a complication of some sort, I was suddenly the local All-Star. Guess what my answer was? "I'm not your doctor. I did not do this operation. You need to return to the original operating surgeon for post-op care regarding this complication."
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Was he being a dick or was he just trying to do the best he can do for himself? I mean not everyone know what routine is.
 
JP2740 said:
Was he being a dick or was he just trying to do the best he can do for himself? I mean not everyone know what routine is.
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I've seen it both ways. Most of the time it's something relatively routine and the patient is being a primadonna.

I was a chief resident at a Midwestern Plastics program several years ago when I received a call from my junior on New Year's Eve afternoon. Mrs VIP had been seen by my chairman around six months earlier in consult for breast recon. She had told him, "I don't want residents and I want the very best." He told her that he doesn't do anything without his residents and that he considered his breast recon work to be comparable to anyone else in the field. She ultimately decided to go to Major Cancer Hospital to have tissue expander recon. FFW to New Year's Eve and pt is in our ED with infection and threatened exposure of expander. I see pt, she tells me that she doesn't want "any of you residents touching me" and that she'll only see my chairman. I call my chairman (who is not on call) and he says, "If I wasn't good enough for her six months ago, I'm still not good enough for her now. Tell her to buy an airline ticket to Major Cancer Hospital and not to bother us again."

Before anybody gets their panties in a wad, my old chairman took Hand trauma call until he was 70, even during the years when he was ASPS President and ABPS President. He routinely operated on Medicaid and non-pay patients and gave them the same level of care as any VIP-type patient.

This is the problem with going out of town for "the best" on relatively routine surgery. In my Hand fellowship I saw several similar issues (I trained with an international AllStar who frequently had VIPs come in for very routine things). Of course, there are some things that require the services of the AllStar. I have on occasion referred patients to Mayo/MD Anderson/MSK for super-specialty services. In those cases, I communicate with the surgeon that I want to see the patient and volunteer to be the local-eyes available to deal with any issues at home.
 
Good on your former Chairman for having the guts to stand up to Ms. VIP. Not all attendings do that.

On a related topic: I have witnessed a fairly common phenomenon of plastic surgeons operating on their wives and GFs. What's the ASPS's take on this? As you know, I decided to have my carpal tunnel done by a stranger rather than a friend or someone who might be "emotionally invested".
 
Winged Scapula said:
On a related topic: I have witnessed a fairly common phenomenon of plastic surgeons operating on their wives and GFs.
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For cosmetic reasons? That's just wrong. Talk about a conflict of interests.

I once saw a young woman when I was on OB/gyn for a routine eval, and she'd had breast implants done, and she somehow mentioned that it was her boss that did it for her (she worked at a plastics clinic), and I think it was for the price of "on the house." She was a pretty girl, making the whole thing kind of creepy.
 
I don't know if there is an official ASPS statement on operating on wives/girlfriends/office staff. I do know that it is very, very common. I helped one of my attendings do an abdominoplasty/mastopexy on his wife when I was a Chief. I also did the facelift on that attending's office manager. He did it for free, but she had to get photos every day as a flip book for patients to see the "normal" phases of healing. It is very routine for us to operate on our office staff. It's seen as a perk for the staff and they can talk to patients about the experience.

I've been threatening my father with an upper lid bleph for years.
 
maxheadroom said:
I helped one of my attendings do an abdominoplasty/mastopexy on his wife when I was a Chief.
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Seems a little awkward...

I did a breast reduction on a friend, but the attending didn't know her at all. She and her husband thought it was quite amusing.
 
OP, I'm not sure where the person with the hernia is located geographically, but PM me if you're interested in a recommendation for an excellent hernia surgeon in the south (one of my attendings.)


Sent from my iPhone using SDN mobile
 
epsilonprodigy said:
OP, I'm not sure where the person with the hernia is located geographically, but PM me if you're interested in a recommendation for an excellent hernia surgeon in the south (one of my attendings.)
Sent from my iPhone using SDN mobile
Click to expand...

It's been 4 years since this thread was started, so I'm guessing the hernias have been repaired by now...
 
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epsilonprodigy said:
OP, I'm not sure where the person with the hernia is located geographically, but PM me if you're interested in a recommendation for an excellent hernia surgeon in the south (one of my attendings.)


Sent from my iPhone using SDN mobile
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I'm interested in a recommendation for hernia surgeon. Thank you!
 
On a similar note (not to steal the thread), what procedures would you consider going to a Hopkins, Mayo, Harvard, WashU, Stanford, etc type of place vs. going to the local good community hospital or average teaching hospital?
 
TimesNewRoman said:
On a similar note (not to steal the thread), what procedures would you consider going to a Hopkins, Mayo, Harvard, WashU, Stanford, etc type of place vs. going to the local good community hospital or average teaching hospital?
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Surgeries that require a trip to famous ivory towers such as Mayo/MDA/MSKK are rare, and usually some reoperative disaster, e.g. hemicorporectomies for recurrent rectal cancer. Anytime such a surgery is rare, it often has blurry indications and a controversial risk to benefit ratio.

A much more common scenario is the need for referral to a tertiary or quaternary center. In my world, it's been shown that rectal cancer patients do much better when they are treated at high-volume centers by high-volume surgeons.

Once you step outside of the bread and butter surgeries for any given specialty, you'll find that the outcomes are better at high-volume centers with high-volume surgeons. Therefore, the case list is seemingly endless.
 
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SLUser11 said:
Surgeries that require a trip to famous ivory towers such as Mayo/MDA/MSKK are rare, and usually some reoperative disaster, e.g. hemicorporectomies for recurrent rectal cancer. Anytime such a surgery is rare, it often has blurry indications and a controversial risk to benefit ratio.

A much more common scenario is the need for referral to a tertiary or quaternary center. In my world, it's been shown that rectal cancer patients do much better when they are treated at high-volume centers by high-volume surgeons.

Once you step outside of the bread and butter surgeries for any given specialty, you'll find that the outcomes are better at high-volume centers with high-volume surgeons. Therefore, the case list is seemingly endless.
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Sure, I was just curious where the personal line was for some of the surgeons on this board. Would it be whipped, large liver resection, multiple valves, crani, AAA?
 
TimesNewRoman said:
Sure, I was just curious where the personal line was for some of the surgeons on this board. Would it be whipped, large liver resection, multiple valves, crani, AAA?
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Probably ex vivo resection... I'd probably go to Cato at Columbia for that if I really wanted it done.
Large liver resection I'd go to a quaternary center, but not necessarily any particular surgeon. Plenty of people that specialize in them.
Redo liver transplant or if it was a high meld with portal vein thrombosis I'd also go to a big name center (which is probably the only place that'd consider you as many programs won't Transplant them)
 
TimesNewRoman said:
Sure, I was just curious where the personal line was for some of the surgeons on this board. Would it be whipped, large liver resection, multiple valves, crani, AAA?
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Within Urology the only procedure I would strongly recommend referral to a quaternary center would be for an RPLND for testicular cancer, especially in the post-chemo or reop setting. Otherwise there is some data showing that cystectomy patients to better at high volume centers, but the standard for "high volume" in the literature is surprisingly sparse, meaning if your hospital did more then 6 cystectomies/year, you were considered a high volume center.
 
Important to distinguish between high volume center and msk/mayo/Hopkins etc. Those are certainly high volume centers but they aren't the only ones, and depending on the procedure do not have better outcomes. For whipple for example, high volume means 12/yr. There are probably 50 or so places that meet that criteria, maybe more, but most of the improvement in outcome comes from post op management of complications, not unique surgical skill or super sharp knives.
 
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TimesNewRoman said:
On a similar note (not to steal the thread), what procedures would you consider going to a Hopkins, Mayo, Harvard, WashU, Stanford, etc type of place vs. going to the local good community hospital or average teaching hospital?
Click to expand...

Mesothelioma surgery. And I'd send them to Sugarbaker.
 
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DoctwoB said:
Within Urology the only procedure I would strongly recommend referral to a quaternary center would be for an RPLND for testicular cancer, especially in the post-chemo or reop setting. Otherwise there is some data showing that cystectomy patients to better at high volume centers, but the standard for "high volume" in the literature is surprisingly sparse, meaning if your hospital did more then 6 cystectomies/year, you were considered a high volume center.
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I thought that was a common operation for Urology... The guys I trained with did a ton of them.
 
ThoracicGuy said:
I thought that was a common operation for Urology... The guys I trained with did a ton of them.
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Which, cystectomies or RPLNDs? Cystectomies are reasonably common at any tertiary center, at my institution we probably do ~150/year. The problem is that there are a lot of people/centers doing 0-1 a year, thus making any center doing >6/year a top quintile or "high volume" center, which is what all the volume-outcome data is based on. Thus for cystectomies there is good data that you should go somewhere like your local academic institution, but no data that you need to go to MSK or USC
 
DoctwoB said:
Which, cystectomies or RPLNDs? Cystectomies are reasonably common at any tertiary center, at my institution we probably do ~150/year. The problem is that there are a lot of people/centers doing 0-1 a year, thus making any center doing >6/year a top quintile or "high volume" center, which is what all the volume-outcome data is based on. Thus for cystectomies there is good data that you should go somewhere like your local academic institution, but no data that you need to go to MSK or USC
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RPLND. I'm not sure what their cystectomy volume was.
 
As @vhawk points out, high volume doesn't only occur at places like MSK, UCSF, MDA etc.

For example, we have a couple of local guys (in private practice) who do over 100 Whipples per year. I'd probably go to them if I needed one.

IMHO the time for big name places is more about the surgeon: like others have said, major re-operative stuff, extremely rare, and clinical trials only available there would be my reasons.

I frankly wasn't so impressed with the care my brother got for his RCC at "big name hospital"; almost all care delegated to residents who didn't seem to communicate with the attending (or vice versa) because at the post op visit he seemed totally unaware of hospital events. Didn't refer for clinical trial (of which there were several active ones locally he was eligible for), didn't make any followup after the first post op visit, even though he didn't have pathology, promising he'd call when he did (we called multiple times and finally got a copy when my SIL marched over there 3 weeks post op), nursing staff who seemed more interested in snowing him than anything (for some reason he appeared to be on a a Bariatric Unit, which made for fun times when my BMI of 21 brother wondered why his meal tray was rather light), and an attending surgeon who talked down to us, only changing his behavior when he recalled what my profession was. "Technically very good but his clinical skills are a little weak" per the Chief of Staff when I complained.

/rant about big name hospitals/surgeons
 
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They really do over 100 whipples a year? Thats....like, a lot. I'd be surprised if there are more than 10 people in the country who do 100 a year, if even that. I mean Cameron is just over 2k and he's been at it for over 45 years.
 
vhawk said:
They really do over 100 whipples a year? Thats....like, a lot. I'd be surprised if there are more than 10 people in the country who do 100 a year, if even that. I mean Cameron is just over 2k and he's been at it for over 45 years.
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Yep.

When I first moved here I would hear the general surgeons talking about these guys and how quick they were, their volume etc. and I wasn't sure that I believed it until I saw with my own eyes.; thought it was all hyperbole at first until I would see the cases on the OR schedules.

Arizona Transplant Associates: Dr. Koep, Dr. Cashman, and Dr. Brink
 
There's certainly some surgeries where there's a high enough volume to quality link with devastating enough consequences if it is poorly performed that I'd go to a mecca.

Probably the easiest example is resection of a pituitary adenoma. The higher volume=lower rate of diabetes insipidus data is clear enough that there's probably a half dozen centers in the country max I'd personally want it done.
 
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Winged Scapula said:
Yep.

When I first moved here I would hear the general surgeons talking about these guys and how quick they were, their volume etc. and I wasn't sure that I believed it until I saw with my own eyes.; thought it was all hyperbole at first until I would see the cases on the OR schedules.
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During residency there was a guy who would book 2-3 Whipples on any given day. He could do them in 3 to 3 1/2 hours.
 
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Buzz Me said:
During residency there was a guy who would book 2-3 Whipples on any given day. He could do them in 3 to 3 1/2 hours.
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One of the private practice guys I trained with could, with a competent chief resident (ahem, me) average about 3-3.5 hrs. Then again he was never doing vein recons, big tumors, basically stuck to the "Chipshot" whipples, but he was pretty quick and slick. We never did THREE in a day (i'm a bit skeptical of that, both because thats still a long ****ing day, and....how busy is he? Does he just operate one day a week?) but we did two sometimes.
 
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Winged Scapula said:
As @vhawk points out, high volume doesn't only occur at places like MSK, UCSF, MDA etc.

For example, we have a couple of local guys (in private practice) who do over 100 Whipples per year. I'd probably go to them if I needed one.

IMHO the time for big name places is more about the surgeon: like others have said, major re-operative stuff, extremely rare, and clinical trials only available there would be my reasons.

I frankly wasn't so impressed with the care my brother got for his RCC at "big name hospital"; almost all care delegated to residents who didn't seem to communicate with the attending (or vice versa) because at the post op visit he seemed totally unaware of hospital events. Didn't refer for clinical trial (of which there were several active ones locally he was eligible for), didn't make any followup after the first post op visit, even though he didn't have pathology, promising he'd call when he did (we called multiple times and finally got a copy when my SIL marched over there 3 weeks post op), nursing staff who seemed more interested in snowing him than anything (for some reason he appeared to be on a a Bariatric Unit, which made for fun times when my BMI of 21 brother wondered why his meal tray was rather light), and an attending surgeon who talked down to us, only changing his behavior when he recalled what my profession was. "Technically very good but his clinical skills are a little weak" per the Chief of Staff when I complained.

/rant about big name hospitals/surgeons
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If I needed a whipple, there is a decent chance I would say **** it and sign up for hospice and spend what time I could on a beautiful beach somewhere. Maybe the outcomes at my low volume training institution unfairly biased me though so I would probably see someone high volume for a consult at least.
 
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dpmd said:
If I needed a whipple, there is a decent chance I would say **** it and sign up for hospice and spend what time I could on a beautiful beach somewhere. Maybe the outcomes at my low volume training institution unfairly biased me though so I would probably see someone high volume for a consult at least.
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I guess it would depend on what I needed the whipple for. AdenoCA? See ya, headed to Margaritaville. Low-grade neuroendocrine tumor? Probably would sign up.
 
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