Causes of Failed Hernia Repairs Done By Experts

Causes of Failed Hernia Repairs Done by Experts

Suvretta Meeting St. Moritz, 2006

Arthur I. Gilbert, Jerrold Young, Michael F. Graham Hernia Institute of Florida

Causes of Failed Repairs by ExpertsCauses of Failed Repairs by Experts

Who is an Who is an expertexpert??What is a What is a failed repairfailed repair??Can we categorize Can we categorize causescauses??

What makes a hernia expert?What makes a hernia expert?

The number of repairs one has done?The number of repairs one has done?Achieved excellent results with one Achieved excellent results with one

technique?technique?Achieved excellent results with many Achieved excellent results with many

techniques?techniques?Done a series and evaluated it? Done a series and evaluated it? Lectured on it?Lectured on it?Published on the subject?Published on the subject?

What is a failed repair?What is a failed repair?

RecurrenceRecurrenceChronic painChronic painUpper GI dysfunctionUpper GI dysfunction

Location of hernias reviewedLocation of hernias reviewed

GroinGroinVentralVentralIncisionalIncisionalHiatalHiatal

Suvretta Meeting Assignment:Suvretta Meeting Assignment:Current Two-Group Personal SurveyCurrent Two-Group Personal Survey

(electronic mail)(electronic mail)Group #1 (N=112): Group #1 (N=112):

Senior authors in HERNIA, 2003-2005Senior authors in HERNIA, 2003-2005Recognized and often quoted hernia expertsRecognized and often quoted hernia experts

Group #2: (N=62)Group #2: (N=62) Invitees to the 2006 Suvretta conferenceInvitees to the 2006 Suvretta conference

Group #1Group #1

Initial email sent to 112 surgeonsInitial email sent to 112 surgeons““What do you think are the most What do you think are the most

frequent causes of failed repairs by frequent causes of failed repairs by experts?”experts?”

12 of 112 emails returned as “undeliverable”12 of 112 emails returned as “undeliverable”Of the assumed 100 received email requests Of the assumed 100 received email requests

answers were answers were received from 46 surgeonsreceived from 46 surgeons

Categories of Causes of Hernia Repair Categories of Causes of Hernia Repair Failure - CHRF (all locations)Failure - CHRF (all locations)

Groups #1 & #2Groups #1 & #2

Surgeon’s personal preparationSurgeon’s personal preparation Training – Experience - AbilityTraining – Experience - Ability

Patient profile and habitsPatient profile and habits Intraoperative factorsIntraoperative factors Wound problemsWound problems Postoperative eventsPostoperative events

Group #1 Groin HerniasGroup #1 Groin Hernias: CHRF by experts: CHRF by experts

1. Surgeon’s personal preparation 36/169

Poor understanding of anatomy/pathophysiology 7Poor training in Lap hernia repair 7Surgeon’s limited experience 6Poor training in open hernia repair 5Failure to recognize multiple defects 4Ignorance of MPO 3Poor teaching of residents 2Surgeon’s age-related factors 1Non expert pressured to do LIH vs. lose case 1


2. Patient profile and habits 12/169

Collagen disorders 4Smoking 3Obesity 2Genetic factors 2 Ascites 1


3. Intraoperative factors 101/169

Inadequate dissection 13Repair without mesh 10Inadequate size of mesh 10Technical mistakes 9Inadequate overlap of mesh 9Errant fixation of mesh 7Plug migration 6Tension in repair 5Plug not in pp space for direct hernias 5Choice of wrong procedure 4Missed hernia sac 4Mesh wrongly placed 3Lichtenstein poor shutter reconstruction 3No coverage of femoral canal from groin 3Incision too small 2Unrecognized lateral hernias 2Lichtenstein poor overlap at pubis 2LIH poor closure of keyhole 2Wrong anesthetic modality 2


4. Wound problems 17/169

Infection 8Mesh shrinkage 3Hematoma 2Use of absorbable suture material 2Intestinal obstruction 1

Seroma 1


5. Postoperative events 3/169

Strenuous activity too soon 3

Group #1 Group #1 Ventral HerniasVentral Hernias: CHRF by experts: CHRF by experts

Surgeon’s personal preparation 16/140

Poor understanding of anatomy and physiology 7 Surgeon’s limited knowledge, experience, and skill 5

Surgeon underestimating extent of hernia 4


Patient profile and habits 20/140

Genetic factors 7 Obesity 4 Collagen disorders 4 Previous contaminated or infected wound 3 Smoking 1 Concurrent diastasis recti 1

Group #1Group #1 Ventral HerniasVentral Hernias: CHRF by experts: CHRF by experts

Intraoperative factors 86/140

Failure to use mesh 14Mesh too small 13Tension on repair 12Inadequate fixation of mesh 12Inadequate overlap of mesh 10Using onlay method of mesh repair 7Overlooked multiple defects 5Failure to use component separation tissue repairs 3Poor exposure 2Inadequate dissection 2Wrong anesthetic modality 2Rapidly absorbing suture material 2Lap hernia poor alignment of mesh 1Fascia not strong enough for repair 1


Wound problems 16/140

Infection 11Seroma 3Hematoma 2


Postoperative events 2/140

Resuming forceful activity too soon 2

Group #1 Group #1 Incisional HerniasIncisional Hernias: CHRF by experts: CHRF by experts


Surgeon underestimating extent of hernia 11Poor understanding of anatomy and Physiology 3Surgeon’s limited knowledge, experience, and skill 2

Group #1Group #1 Incisional HerniasIncisional Hernias: CHRF by experts: CHRF by experts


Obesity 7Genetic factors 6Smoking 3Collagen disorders 1Previous contaminated or infected wound 1Not fully prepared preoperative. 1



Mesh too small 15Inadequate fixation of mesh 13Inadequate overlap of mesh 11Tension on repair 10Inadequate exposure 9Inadequate dissection 8Overlooked multiple defects 8Using onlay method of mesh repair 8Fascia not strong enough for tissue repair 3Failure to use mesh 3Fixation failure at iliac crest and/or pubis 2Lap hernia inadequate lysis of adhesions 2Inadequate lysis of adhesions open procedure 2Rapidly absorbing suture material 1Lap hernia sutures breaking or tearing tissue 1Bowel injury 1

Failure to use component separation tissue repairs 1



Infection 9Hematoma 3Mesh shrinkage 1



Resuming forceful activity too soon 2 Drains removed too soon 1

Group #1Group #1 Hiatal HerniasHiatal Hernias: CHRF by experts: CHRF by experts


Surgeon’s limited knowledge, experience, and skill 9Poor understanding of anatomy and physiology 2Surgeon underestimating extent of hernia 4

No. Surgeons that don’t do this operation 11 of 46



Obesity 4Collagen disorders 3Poor Preop evaluation 2



Inadequate fixation of mesh 13 Failure to use mesh 9Inadequate dissection 8 Tension on repair 8Crura too tight or too loose 8Short esophagus 4Failure to remove hernia sac 3Inadequate exposure 3Fascia not strong enough for tissue repair 3Lap Division of the Short gastric vessels 3Not approximating crura 2Suture tear through 2Fixation failure at iliac crest and/or pubis 2Lap hernia inadequate lysis of adhesions 2Inadequate lysis of adhesions open procedure 2Mesh too small 1Rapidly absorbing suture material 1Lap hernia sutures breaking or tearing tissue 1Bowel injury 1



Infection 9Hematoma 3Not anchoring fundoplasty 2Mesh shrinkage 1Slipped Nisson 1

Group #1 Group #1 Hiatal HerniasHiatal Hernias: CHRF by experts: CHRF by experts


Vomiting or gagging 4 Resuming forceful activity too soon 2

Group #2: Group #2: (Invitees to this Suvretta meeting)(Invitees to this Suvretta meeting) 14 of 62 responders14 of 62 responders

Causes of Hernia Repair Failure (CHRF) related to Causes of Hernia Repair Failure (CHRF) related to specific techniques specific techniques

[only 4 of 14 provided personal information][only 4 of 14 provided personal information]

Onlay mesh repairOnlay mesh repairMesh plug repairMesh plug repairUnderlay (Laparoscopic and Open)Underlay (Laparoscopic and Open)

Group #2: Group #2: (Invitees to this Suvretta meeting)(Invitees to this Suvretta meeting) 14 of 62 responders14 of 62 responders

““What do believe are the main causes of failure in What do believe are the main causes of failure in the hernias you’ve repaired?”the hernias you’ve repaired?”

[[1 of 14 declined personal information]1 of 14 declined personal information]

Onlay mesh repairOnlay mesh repairMesh plug repairMesh plug repairUnderlay (Laparoscopic and Open)Underlay (Laparoscopic and Open)

Group #2 surgeons: Group #2 surgeons: Groin HerniaGroin Hernia CHRF by experts CHRF by experts

Onlay mesh hernioplasty(10)Onlay mesh hernioplasty(10) Mesh too narrowMesh too narrow Insufficient mesh coverage of pubic tubercleInsufficient mesh coverage of pubic tubercle Mesh kept too flat creating tension in repairMesh kept too flat creating tension in repair Fixing upper edge of mesh with continuous sutureFixing upper edge of mesh with continuous suture Passing the lesser cord through lower suture linePassing the lesser cord through lower suture line Not satisfactory for recurrent groin herniasNot satisfactory for recurrent groin hernias Medial detachment of meshMedial detachment of mesh Missed indirect sacsMissed indirect sacs Mesh avulsed from pubic tubercle Mesh avulsed from pubic tubercle Vypro mesh rolled upVypro mesh rolled up


Plug hernioplasty (4)Plug hernioplasty (4)Doesn't fully protect direct spaceDoesn't fully protect direct spaceShrinkage of plugShrinkage of plugUnusual incidence of postoperative neuralgiaUnusual incidence of postoperative neuralgiaDoesn't fully protect lateral to internal ringDoesn't fully protect lateral to internal ring


Laparoscopic/Open posterior repairs (8)Laparoscopic/Open posterior repairs (8) Overlooked lipomasOverlooked lipomas Not fixing mesh to Cooper ligament in femoral herniaNot fixing mesh to Cooper ligament in femoral hernia Mesh slit not overlapped sufficientlyMesh slit not overlapped sufficiently Mesh contractionMesh contraction Inadequate dissection near iliac vesselsInadequate dissection near iliac vessels Inadequate mesh coverage laterallyInadequate mesh coverage laterally Mesh roll-upMesh roll-up Inadequate inferior dissectionInadequate inferior dissection

Group #2 surgeons: Group #2 surgeons: VentralVentral//IncisionalIncisional CHRF by experts CHRF by experts (12) (12)

Laparoscopic and OpenLaparoscopic and Open Not using mesh for umbilical or ventral hernias Not using mesh for umbilical or ventral hernias Associated with gastric bypass surgeryAssociated with gastric bypass surgery Inadequate size meshInadequate size mesh Not identifying multiple weaknessNot identifying multiple weakness Limited dissectionLimited dissection Insufficient suture fixationInsufficient suture fixation Depending on tack fixation aloneDepending on tack fixation alone Button-hole hernias related to suture fixationButton-hole hernias related to suture fixation Infection following undetected bowel injuryInfection following undetected bowel injury Infection following recognized bowel injuryInfection following recognized bowel injury Infection in mesh from old suture abscessInfection in mesh from old suture abscess Suture pulloutSuture pullout

Group #2 surgeons: Group #2 surgeons: Hiatal HerniaHiatal Hernia CHRF by experts CHRF by experts (5) (5)

Laparoscopic and OpenLaparoscopic and OpenFailure to use mesh Failure to use mesh Inappropriate use or tacks and staplesInappropriate use or tacks and staplesStenosisStenosisEmesisEmesisCrura closed too looselyCrura closed too loosely

99.00% 98.00% 97.00% 96.00% 95.00% 94.00% 93.00%1 0.9900 0.9800 0.9700 0.9600 0.9500 0.9400 0.93002 0.9801 0.9604 0.9409 0.9216 0.9025 0.8836 0.86493 0.9703 0.9412 0.9127 0.8847 0.8574 0.8306 0.80444 0.9606 0.9224 0.8853 0.8493 0.8145 0.7807 0.74815 0.9510 0.9039 0.8587 0.8154 0.7738 0.7339 0.6957 6 0.9415 0.8858 0.8330 0.7828 0.7351 0.6899 0.6470 7 0.9321 0.8681 0.8080 0.7514 0.6983 0.6485 0.6017 8 0.9227 0.8508 0.7837 0.7214 0.6634 0.6096 0.5596 9 0.9135 0.8337 0.7602 0.6925 0.6302 0.5730 0.5204 10 0.9044 0.8171 0.7374 0.6648 0.5987 0.5386 0.4840

#Steps

Probability Table of Successful ResultsRed is the probability of successful completion of each step. Percentages in the table represent the probability of successfully completing the entire processExample: In a 5-step process, if probability of success in each is step 95%, the probability of a successful outcome is .7738.

“Expert surgeons become expert based on repetitive experience, enthusiasm and dedication to a particular field of expertise, hand-eye coordination skills, and intellectual stimulation. Eventual failure of technique is inherent with age, as enthusiasm tends to wane over time,hand-eye coordination skills can diminish, and the fatigue factor plays more of a role with age. (con’t)

A final undeniable thought:

:

As the expert surgeon becomes more known for his/her skills, more work is thrust upon them, which may cause them to rush through their cases, take short cuts that may be inadvisable, and have mental lapses simply due to fatigue which takes more of a toll as we age. (con’t)

Being the expert lends itself to a failure in the expertise, not due to wanton carelessness or overconfidence, but due to the volume of cases and the imperfection of the human being. If you walk a high wire enough times, you will fall. I believe this general statement is applicable for each of the operations requested.”

Donn Schroder, 2005

On becoming an Expert

Expect success: Always look for your own failures.

From your failures come your expertise.

ConclusionsConclusions

Gathering information from Gathering information from expertsexperts is not easy. is not easy. Gather information about Gather information about failurefailure is not easy. is not easy. CausesCauses of failure by experts is no different than for of failure by experts is no different than for

non-experts – attention to detail and principlesnon-experts – attention to detail and principles ProbabilityProbability: More steps, rather than fewer, : More steps, rather than fewer,

dispose to greater chance of failure.dispose to greater chance of failure. There comes a time in every expert’s career when There comes a time in every expert’s career when

technical failures are related to natural factors.technical failures are related to natural factors.

Causes of Failed Hernia Repairs Done By Experts

Documents

Transcript of Causes of Failed Hernia Repairs Done By Experts