What type of surgeon should a patient with a hernia and potential underlying health conditions be referred to for surgical evaluation and repair?

Hernia Repair Surgical Referral

Patients with hernias should be referred to a general surgeon with specialized expertise in abdominal wall surgery, as specialized hernia units demonstrate significantly lower recurrence rates (12.0% vs 28.9%) compared to non-specialized general surgeons. 1

Optimal Surgeon Characteristics

Refer to a general surgeon who:

• Has dedicated expertise in abdominal wall surgery and hernia repair 1
• Possesses proficiency in both open and laparoscopic/endoscopic techniques, as guideline-concordant care requires mastery of multiple approaches 2
• Performs high volumes of hernia repairs, as specialized abdominal wall surgery units achieve superior outcomes 1

The evidence strongly supports that expertise in abdominal wall surgery matters significantly - patients operated on by specialized abdominal wall surgery units have a 63% lower risk of recurrence (OR = 0.19) compared to general surgeons without this specialization 1. This difference persists even when controlling for patient complexity, BMI, and comorbidities 1.

Essential Technical Competencies Required

The surgeon must be proficient in:

Laparoscopic/endoscopic approaches (TEP and TAPP):

• Required for bilateral hernias, recurrent hernias, and all hernias in women 3, 2
• TEP (totally extraperitoneal) is preferred over TAPP due to lower complication and recurrence rates 4
• Laparoscopic repair results in significantly lower chronic pain rates, faster recovery, and lower wound infection rates 3, 5
• Can identify occult contralateral hernias present in 11.2-50% of cases 3

Open repair techniques:

• Essential for emergency presentations with strangulation or peritonitis 6
• Necessary when patients cannot tolerate general anesthesia 3
• Can be performed under local anesthesia for uncomplicated cases, offering fewer cardiac and respiratory complications 3

Mesh repair expertise:

• Mesh repair is the standard approach with significantly lower recurrence rates (0% vs 19% with tissue repair) 3, 5
• Surgeon must understand appropriate mesh selection based on surgical field contamination 7

Special Considerations for Complex Cases

For complicated hernias requiring advanced techniques, ensure the surgeon has expertise in:

• Component separation technique for large midline abdominal wall hernias 7
• Damage control surgery for critically ill patients with peritonitis 7
• Management of contaminated fields with biological or biosynthetic meshes 7

For emergency presentations (incarcerated/strangulated hernias):

• Immediate surgical capability is mandatory, as delayed diagnosis >24 hours significantly increases mortality 6
• Surgeon must be able to assess bowel viability and perform bowel resection if needed 7, 6
• Hernioscopy technique expertise is valuable for assessing bowel viability without unnecessary laparotomy 3, 6

Common Pitfalls to Avoid

Do not refer to surgeons who:

• Only perform one type of approach (open or laparoscopic), as this limits guideline-concordant care 2
• Lack experience with mesh-based repairs, given the pathophysiology involves extracellular matrix abnormalities 2
• Have low hernia repair volumes, as specialized expertise directly correlates with reduced recurrence 1

Critical timing considerations:

• For suspected strangulation (tender mass, anorexia, vomiting, SIRS criteria, elevated lactate/CPK/D-dimer), refer emergently - delays >24 hours increase mortality 6
• For femoral hernias, prioritize urgent referral as they carry an 8-fold higher risk of requiring bowel resection 3