Almost every week, a patient sitting across from me in a consultation asks the same question: if the open preperitoneal mesh repair is such a good operation, why don’t more surgeons offer it?It’s a fair question. The honest answer has less to do with the operation itself and more to do with how surgeons are trained, how they build their careers, and how our field markets itself.
I started as a generalist
I trained as a general surgeon, and I loved it. I loved taking care of really sick people. I learned trauma surgery, and I took out gallbladders and appendixes. General surgery is a broad discipline, and when I trained it was even broader. Thirty to forty years ago, general surgery still included vascular, colorectal, and endocrine surgery, so I learned to do all of it.
In my first few years of practice, I took out parathyroid glands, operated on breast cancer and colon cancer, treated pilonidal disease, removed gallbladders and appendixes, and repaired hernias. That’s the life of a general surgeon, and plenty of excellent surgeons build rewarding careers doing exactly that.
Choosing to be an expert at one thing
Not everyone is content doing one thing over and over again. I am. I know that’s an unusual personality for a general surgeon, but it’s very common elsewhere in surgery. Think of the orthopedic surgeon who only does total knee or hip replacements, or the shoulder specialist who only operates on shoulders.
I learned quickly that I wanted to be an expert, not a generalist. So I’ve spent the last 25 years narrowing my focus. For the last 15 years, I’ve only done hernias. For the last decade, I’ve only done inguinal and umbilical hernias.
That narrowing matters. When you focus that tightly, you start learning techniques that aren’t common or popular, and some of them are hard to learn. The open preperitoneal repair is one of them.
From laparoscopic surgeon to open preperitoneal surgeon
I learned laparoscopic surgery in residency, and after residency, laparoscopic repair was all I did for inguinal hernias. It’s a great operation, and is commonly done by many general surgeons.
When I learned the open preperitoneal repair, though, I came to understand the three-dimensional anatomy of the groin in a way I hadn’t before. I also found a repair that, in my opinion, is less invasive. It accomplishes the same goal as a laparoscopic repair, it doesn’t require general anesthesia, and it doesn’t require entering the peritoneal cavity, the space that holds the intestines.
So I asked myself a simple question. Why wouldn’t I offer my patients that repair? I made the switch almost 23 years ago, and I haven’t looked back.
So why don’t more surgeons offer it?
I think it comes down to three things.
It’s hard to learn. This isn’t a technique you pick up in a weekend course. It takes years to become comfortable with it, and most surgeons in busy general practices don’t have that time. I don’t blame them for that.
It’s open surgery, so it isn’t marketed as minimally invasive. Laparoscopic and robotic surgeons describe themselves as “minimally invasive,” and it’s very effective marketing. The open preperitoneal repair is a minimally invasive operation, but the word “open” works against it. As a result, many surgeons have never heard of what we do.
There’s no outside reason to change. If you’re a skilled laparoscopic surgeon with a busy practice and a strong marketing message, nothing is pushing you to spend years learning something new. Nobody pushed me either. There was no financial or external motivation. I was hungry to learn new procedures, I found what I believed was a better way, and I thought it was better for my patients.
It takes a hernia specialist to teach a hernia specialist
When I hired Dr. Nora Fullington, I trained her on this repair. She was a laparoscopic hernia surgeon before she joined us, and I think that background is exactly what it takes. It really takes a laparoscopic hernia specialist to learn what we do. That makes for a very narrow pipeline: a surgeon who is already a hernia specialist, who is willing to set aside a technique that works and markets well, and who has the drive to learn something new.
What this means for you as a patient
This is the bigger point, and it goes beyond one operation. In my opinion, the best outcomes come from surgeons who do one thing, do it at high volume, and keep refining how they do it. That’s how orthopedics works for knees, hips, and shoulders, and I think hernia surgery should work the same way.
A specialized practice can also offer you options a generalist may not. When a surgeon only knows one approach, every patient tends to get that approach. When a surgeon has spent decades on one problem, the conversation can start with what’s best for you.
If you’re facing an inguinal hernia repair, here are a few questions worth asking any surgeon:
- How many inguinal hernia repairs do you do each year?
- Which approaches do you offer, and why are you recommending this one for me?
- Will I need general anesthesia?
- Will the operation enter the abdominal cavity?
Getting more surgeons to learn this repair is going to take time, more research, and probably some external forces. In the meantime, I’d encourage every patient to ask one more question: is my surgeon offering me the operation that’s best for me, or the operation they happen to know? That’s the standard we hold ourselves to at Boston Hernia, for the benefit of the patient.