MELBOURNE HERNIA CLINIC: 2006 ANNUAL REPORT
Topics
- An audit of all hernia cases was undertaken.
- Website and Internet activities have expanded.
- CME programme in development to teach Rural Doctors online.
- Sydney Hernia Centre was established to cater for clients in Sydney and New South Wales.
- A/Prof Brygel attended the combined Meeting of the European & American Hernia Society.
Summary
- In brief, A/Prof Brygel carried out over 300 hernia operations. The results and outcomes of the surgery were very pleasing. The Audit examines all the pre-operative issues and risks, the surgery undertaken and the results of surgery. These Audits are part of continuing medical education, which all Surgeons undertake. The results are presented to peers and the Royal Australian College Of Surgeons.
- Our Website gets continuing interest from all over Australia and overseas. Some people just email us for information, which is gladly provided. Others come to see us for second opinions or for surgical treatment. A/Prof Brygel has become particularly interested in this trend and has conducted a survey of all patients who attend us via the Internet as to why they do so initially rather than seek referral from a General Practitioner. A/Prof Brygel has researched this and will be presenting a Paper at an International Conference this year entitled ‘Internet Surgery’.
- After helping to conduct a short course in Office Surgery for GP’s at the Royal Australasian College of Surgeons, an online teaching program was initiated that will shortly have QME points associated with it.
- In late 2006 the first steps were taken to establish the Sydney Hernia Centre in Sydney, New South Wales. This came about because of the increasing number of enquiries, which came to us from patients who would like us to carry out their surgery.
- A/Prof Brygel attended an International Hernia Conference in Boston, USA. Apart from hearing about the latest developments it was interesting to meet colleagues from all around the world and to see the presentations from the trade companies regarding all the latest equipment.
Audit
The Hernia Audit for 2006 has been completed.
It showed that A/Prof Brygel operated on over 300 hernias. The vast majority of these were inguinal hernias. The vast majority were treated as a day case under Local Anaesthetic and sedation with a mesh reinforcement – even in 80–90 year olds.
Many of the patients were not insured but were able to be treated privately because of the relatively low cost.
It was rare for any patient to be re-admitted to hospital after day surgery.
All patients who go home the same day were given A/Prof Brygel’s mobile number to ring the following day to confirm that all was well and to receive advice.
Many patients required no painkillers and the majority required painkillers for only one or two days. Most reported that pain had not been a significant problem. There are a small percentage of patients where pain persists for longer and the patient feels that pain has been a significant factor. These usually settle down within a few more days.
No-one complained that going home the same day was inappropriate. In fact patients loved it.
Many people are able to return to office type work after a few days. Those on heavy jobs took longer off work.
The infection rate was extremely low – under 1%. Patients, where an infection is a possibility, such as those who have got immunosuppression and have a type of hernia which may become infected, are given an antibiotic cover. However the use of antibiotics are kept to a minimum because of the risk of adverse reactions and supra-added infection, as well as development of resistance.
A/Prof Brygel and Mr Leinkram were particularly pleased regarding the results of the Audit we carry out on all our hernia patients. This showed very few significant problems. In particular infection was rarely a problem and many patients required no painkillers whatsoever. In addition A/Prof Brygel has taken an interest in this trend and has conducted a survey of the patients who came via the Internet or looked him up on the Internet even after referral from their own General Practitioner. There appeared to be a variety of reasons and A/Prof Brygel will be presenting a paper on this at an International Conference this year. It will be titled “Internet Surgery”.
Internet and Website
On the 19th February 2007 the Editor of the Medical Journal Of Australia wrote, he was very critical that public hospitals have depersonalised medical staff and the senior medical staff at hospitals. One of the arguments for this might be that treatment of patients is a team affair. However the Editor implied that it is ultimately the Surgeon who is responsible. This led me to believe – together with opinions obtained from some of our patients – that people are interested in knowing more about the Surgeon they are going to see. We have attempted to fulfil this on our Internet site.
We also continue to develop our Internet activities. It is found more and more patients were coming to us through the Internet. Many of the patients were from country Victoria and even Interstate. This has led us to the idea of setting up in Sydney. We are in the early stages of this.
The Internet has become increasingly popular with the public as a tool to seek out information regarding medical conditions.
The Melbourne Hernia Clinic receives numerous enquiries directly by email or by telephone or fax from all over Australia and overseas – particularly expatriate Australians.
Advice is often sought regarding hernia problems and we are pleased to respond to these requests. It must however be realised that advice regarding complex problems can only be given after a full history and examination. We are however pleased to help point patients in the right direction.
By reading this you have showed that you are interested in hernias on the Internet. We have surveyed the figures in our practice of patients who came through the Internet.
Basically nearly 1/3 of our patients discovered they had a hernia, looked us up on the Internet, and came for surgery.
We were particularly pleased with this result and the confidence that is shown in our site and us. We are open to suggestions on how to improve the site.
In addition many patients who were referred to us directly from their General Practitioner, also looked us up on the Internet to be sure that they were happy with what they were getting.
About half the patients from the Internet were from Melbourne – all over Melbourne. One quarter were from country Victoria and another quarter were from Interstate or overseas – mostly expatriates who found it convenient to come back to Melbourne for treatment. This included patients from Namibia, Borneo and Fiji.
We did a survey on the reasons why patients chose us after looking on the Internet. There were a variety of factors.
Those that seem to be important were:
- A specialist in that field,
- Many prefer to avoid a General Anaesthetic,
- Many wish to avoid long waiting lists in the public system or even in the private system in some cases,
- Many patients who are unhappy with the opinion they were given or with difficulty in trying to make an appointment or the reception they received.
It is difficult to put our finger on the one reason for the success of the Internet site, but we guess it boils down to confidence.
I would like to thank our Office Staff, Di and Gill, who get many compliments from the patients who enquire because of the tact with which they are handled and their questions answered.
The majority of patients now contact our office directly, but Interstate and overseas patients often send an email which we undertake to reply to promptly.
In addition to those patients who actually come to see us we do receive many enquiries from patients who have specific problems particularly with family who are elderly or who have complications.
Handling these does take some time and we are happy to respond to these enquiries and try to give appropriate advice. One has to bear in mind that without taking a history and examining the patient we cannot give a full advice but we are usually able to put the patient on the right track.
Thus the Internet has added a new dimension to our practice of hernia surgery.
If you have any queries please let us know.
European and American Hernia Societies Conference (Boston, USA)
This occurred over four days in June 2006. There were over 1000 attendees but very few from Australia.
Whilst there I met Dr Martin Kurzer of the British Hernia Centre. I had visited the British Hernia Centre in London on two previous occasions to observe their work and have discussions.
The British Hernia Centre carries out most hernia repairs using the open technique with a Local Anaesthetic infiltration and a mesh reinforcement. This broadly follows what is described as the “Lichtenstein” tension free technique. The key component is the use of Local Anaesthesia rather than General Anaesthesia. Lichtenstein popularised this technique in Los Angeles. It gives excellent results in most hands – it is very safe.
At the Conference many other techniques were also presented. Hernias worldwide have become an enormous business, as hernias are one of the commonest general surgical operations. The mesh used in the repair can cost anything between $70 – $300. In addition for laparoscopic (keyhole), expensive disposable equipment is used.
There has been intense research to develop better or alternative methods of repair for hernias. The idea is to obtain the perfect result – that is no complications to the operation – no pain after the operation – no recurrences and an almost immediate return to work. We strive for these results.
There is no doubt that the use of mesh either by the open method, with or without plugs, or by the laparoscopic method has revolutionised hernia surgery. However, it has been suggested by some that the mesh used in surgery can contribute to ongoing pain at the site of the hernia operation in a small percentage of patients and can even last for several years.
As a result companies are producing lighter weight meshes, which partially absorb. They suggest that this will reduce the incidence of pain.
Audit has shown that persisting pain in our hands has not been a common problem.
Some conference participants were concerned that altering the mesh might lead to an increase in the incidence of recurrence. We do occasionally use these lightweight meshes, but it is unclear if there is any difference in the pain post-operatively or the recurrence rate.
At the Conference acknowledged experts presented their favourite methods of repair – almost all use mesh.
Whilst it is commonplace in the US, Europe and at the British Hernia Centre to repair hernias under Local Anaesthetic and sedation, this technique does not appear to have found favour in Australia for reasons, which are found difficult to explain.
There was general agreement that the Shouldice Clinic in Canada gets excellent results using a suturing technique in layers. However, most clinics have not been able to reproduce their results.
Most agree that the Lichtenstein, British Hernia Centre technique and the method favoured by ourselves gives excellent results.
In addition there are now several techniques where the mesh is placed behind the muscles. These techniques can be used under Local Anaesthetic but more commonly require a General Anaesthetic. These meshes generally use a larger and heavy material.
Keyhole Surgery (laparascopic)
This technique has its proponents in Australia and worldwide. However many Surgeons are against the technique because:
- It requires a General Anaesthetic,
- Extensive dissection is required,
- There are inherent risks in the procedure, which are not present with the open technique.
- We believe the recurrence rate is no better and could even be higher.
- It is more expensive.
Many Surgeons believe that any possible benefits do not outweigh the possible risks. There is a much longer learning curve to become an expert in this technique than by the open method. The results are therefore, operator dependent and less consistent than with the open method.
In particular A/Prof Brygel does not feel there is less pain post-operatively with the “keyhole” technique than with the open technique, which he uses particularly when Local Anaesthetic and the tension free method are undertaken. Less pain is one of the stated benefits of the keyhole technique.
Thus hernia surgery is in evolution and new ideas are constantly being presented and assessed.
We specialise in hernia repair under Local Anaesthetic and sedation with a mesh reinforcement as a day case. However, there are particular patients who benefit from different techniques because of peculiar circumstances.
We have a team of experts who have expertise in each field of repair and an appropriate choice is made for each patient.
Conclusion
Thus patients over the Internet are looking for a Specialist whom they can identify with, have easy access and prompt surgery for the insured or even non-insured.
Patients have a right, and these days expect to be able to choose the type of treatment they prefer. Whilst I personally favour the open tension free technique under Local Anaesthetic with mesh, we have other Surgeons who prefer the keyhole technique and other varieties.
In addition we have at our clinic Mr Charles Leinkram, who has a special interest in incisional hernia repair together with abdominoplasty where appropriate – that is a tummy tuck operation.