Outpatient Surgery Magazine

OR Excellence Awards - September 2020 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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of surgery at the University of Tennessee College of Medicine in Memphis. "These are the patients you have to be very careful with." That's because the pain the patient is experienc- ing usually isn't coming directly from the hernia. While hernias are undoubtedly uncomfortable, most aren't that painful, says Dr. Mazin. "If there's a lot of pre-op pain, the surgeon has to look into other causes of it," he adds. 3. Rely on surgeon skill Ultimately, the post-op success of your facility's hernia repairs is contingent upon the skill of your surgeons. "The ability of the surgeon is one of, if not the single most important factor, in preventing post- op pain," says Dr. Voeller. And although tens of thousands of hernia repairs are done on an outpa- tient basis each year, the procedures require a tremendous amount of skill. "These are laborious, meticulous procedures that require an exquisite attention to anatomical detail on the part of the sur- geon," says Dr. Mazin. This attention to detail is absolutely critical because surgeons are operating in close to proxim- ity to several sensory nerves. "With an inguinal hernia repair, the groin has a number of sensory nerves that are at risk during the surgery itself or during the scarification process afterward," says Dr. Voeller. Specifically, notes Dr. Mazin, surgeons must be aware of where they're operating in relation to the iliohypogastric, ilioinguinal and genitofemoral nerves, and avoid them at all costs. In terms of technique, there's compelling evi- dence that a minimally invasive approach is superi- or to an open one in terms of preventing post-opera- tive pain. "Virtually every study shows that properly done minimally invasive repairs will have less acute pain and less chance of chronic long-term pain than open repairs," says Dr. Voeller. That's because the way mesh is placed during open repairs can cause the sensory nerves to scar into the repair area, which leads to a higher incidence of chronic pain. With laparoscopic mesh place- ment, surgeons work behind the muscle so the mesh doesn't sit on those nerves and there's less chance of the nerves scarring into the mesh, adds Dr. Voeller. So surgeons should always perform laparoscopic hernia repairs then, right? It's not that simple. Surgeons who perform these repairs need to do a high volume of them because of the skill and atten- tion to detail required. 4. Find the right mesh When it comes to mesh, Dr. Mazin has some simple, straight-forward advice for surgeons who use it and facilities that purchase it: "There is a multiplicity of meshes on the market, and most are good. Surgeons should focus on finding something they're comfortable placing, do it well and learn to repro- duce the procedure again and again." In other words, don't get bogged down in the abundance of options when virtually any type of mesh can give you great results if an adept surgeon who's comfortable with the material implants it. "There's really no evidence in the average patient that the mesh type has an effect on the outcomes," says Dr. Voeller. However, he does understand the financial com- ponent of stocking the right type and amount of mesh, and navigating the endless vendor options — particularly for smaller ASCs where cost-con- trol is critical. To that end, Dr. Voeller offers some advice for facility leaders. "Find a knowledgeable surgeon who can assess mesh in an unbiased way to let you know the one or two products you should be carry- ing," he says. "Outpatient facilities really need a sur- geon who can look at the data and say, 'OK, these are the cost-effective ways to fix hernias.'" It goes without saying that cost-effective hernia repairs should always focus first and foremost on successful, pain-free outcomes for patients. OSM 6 0 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • S E P T E M B E R 2 0 2 0 "Surgeon ability is one of the most important factors in preventing post-op pain." —Guy Voeller, MD, FACS

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