we accept the realization that biologic complexity and biologic vari-
ability 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 prod-
ucts. 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, collabo-
rate 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-popu-
lations 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,
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