Surgeons' Attitudes Variable on Hernia Repair in Women of Childbearing Age

By Linda Carroll

March 30, 2020

(Reuters Health) - Surgeons' opinions on abdominal hernia repair in women of childbearing age are quite variable, a small survey finds.

Based on interviews with 21 surgeons about approaches to abdominal hernia repair in women of childbearing age, researchers found the physicians fell into three groups: those who did not consider childbearing to be a factor; those who suggested delaying until childbearing was done; and those who would discuss benefits and risks and come up with a plan based on patient preference, according to the results published in JAMA Surgery.

"We knew that there was a lot of variation in how surgeons go about managing hernias in different patients," said coauthor Sara Jafri, a research assistant at the University of Michigan's Center for Healthcare Outcomes and Policy, in Ann Arbor. "You could go to one surgeon who would have one approach to this kind of surgery with these parameters and go to a different surgeon and you might get a totally different answer."

"While data suggest that repairs should ideally occur following completion of all pregnancies, adherence to these guidelines varies considerably among surgeons," Jafri and her colleagues write in their report.

For the study, 21 physicians from across the state of Michigan were presented with a clinical vignette featuring a 25-year-old woman seeking elective repair of a symptomatic 2-cm umbilical hernia; they were then then asked how they would approach the case.

When surgeons did not specifically address the woman's age in their answers, interviewers followed up asking if it made a difference that the woman was of childbearing age. At that point, some chose to amend their responses to say that it was an important factor, Jafri said.

But some stuck with their original responses. One, for example, said "you cannot get a promise from somebody that they will never get pregnant again any more than you can get a promise from somebody they won't get fat . . . You operate on them the way they are. I don't change my approach because they might. They might. They might not."

Another responded: "whether or not she's going to have children, it doesn't really matter . . . the fact that she's symptomatic and the risk of further problems with incarceration, or the hernia growing would be sufficient to warrant repair."

Surgeons who opted to delay definitive repair said they would suggest temporary repairs, avoiding mesh use. One responded: "if it's uncomfortable . . . then we may talk about doing a primary repair with the understanding that its durability is lower, but that we may do a more definitive repair at completion of their childbearing."

Surgeons who said they would go with patient preference said they would explain the risks and benefits of doing the repair now. "I would speak to her about open repair versus laparoscopic repair versus robotic repair . . . I'd leave it up to her and give her the potential morbidities, mortalities for each of the repairs."

Ultimately, Jafri said, "we want to call attention to individualizing care and bring to everyone's attention that there are specific factors that impact females differently than males."

The new findings didn't surprise Dr. Gina Adrales, chief of the division of minimally invasive surgery at Johns Hopkins Medicine, in Baltimore.

"I would argue that shared decision making should really be the approach based on the available evidence," Dr. Adrales said, adding that at present there isn't overwhelming evidence on the topic. "At the end of the day, the patient has to go home and live with the pain."

Dr. Adrales took issue with the follow-up questioning of physicians who didn't initially bring up childbearing as a factor. "They might be responding to what they thought might be the right answers," she explained.

"Currently there's little known about female sex and hernia repair," Dr. Adrales said. "Most of what we know is based on population-based studies, which show there are worse outcomes for females than males even when obesity is accounted for. Also, female groin hernias are underdiagnosed. Women are getting shuffled to other doctors for groin pain."

SOURCE: JAMA Surgery, online March 25, 2020.