Surgeon Attitudes and Beliefs Toward Abdominal Wall Hernia Repair in Female Patients of Childbearing Age

Abstract

This qualitative study examines surgeon’s thoughts on decision-making in repairing an abdominal wall hernia in a woman or girl of childbearing age.

A substantial knowledge gap exists in understanding sex as a biological variable for abdominal wall hernia repair, specifically regarding female patients of childbearing age.^1,2,3 While data suggest repairs should ideally occur following completion of all pregnancies, adherence to these guidelines varies considerably among surgeons.^4,5,6 Moreover, wide variation in operative timing, technique, and mesh use exists. Surgeon motivation and behavior contributing to this variability is unknown. Whether and how a potential pregnancy influences surgeon decision-making in regards to operative timing and approach remains inadequately characterized. In this context, we sought to understand surgeon consideration of childbearing age and intent when managing abdominal wall hernias in women and girls.

Methods

This qualitative study used purposive sampling to identify 21 surgeon participants through the Michigan Surgical Quality Collaborative from community and academic hospitals from 5 health regions across the state of Michigan. Participants were diverse with respect to years in practice, practice type, and practice location. The University of Michigan Medicine institutional review board approved this study as exempt, and verbal informed consent was obtained from all participants.

Interviewees were presented a clinical vignette featuring a 25-year-old woman seeking elective repair for her symptomatic, 2-cm umbilical hernia. This vignette was specifically tailored to capture surgical approaches and factors motivating abdominal wall hernia repair decision-making in female patients of childbearing age. All interviews were conducted in person or by phone, digitally audio recorded, deidentified, and transcribed verbatim. Interviews continued until thematic saturation was reached. Through inductive and deductive thematic analyses using NVivo version 11.4.3 (QSR International), the research team located, analyzed, and identified patterns within the data (eAppendix in the Supplement). Data were collected from May 2018 to July 2018 and analyzed from July 2018 to November 2019.

Results

Interviews revealed 3 broad factors characterizing surgeon decision-making for this population, which were categorized as not considered, delaying because of family planning, and patient preference. In the not-considered group, respondents definitively stated, even after interviewer prompting, that childbearing intent would not affect operative decisions. In the group delaying because of family planning, surgeons reported electing approaches that minimized the patient’s risk of hernia recurrence or complication during pregnancy by delaying definitive repair until the completion of childbearing. In symptomatic cases, surgeons offered temporary primary repairs, avoiding mesh use. In the group emphasizing patient preference, surgeons reported the importance of thorough discussions, with many recommending a shared decision-making process in which the patient and surgeon both contributed to the final decision.

Notably, mention of childbearing as a management consideration of the patient presented in the clinical vignette often required interviewer prompting. This led some participants to amend their response according to the aforementioned themes. The Table demonstrates derived factors with representative quotes.

Table. Participant Quotes.

Group	Participant quotes
Not considered
Participant 21	“…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…If you get pregnant and/or...fat, your hernia repair may blow out. But I don’t change the approach because they might. They might. They might not.”
Participant 4	“Whether or not she's going to have children or not, 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.”
Delaying because of family planning
Participant 18	“...If the discussion is that she is still planning on having children, then I would probably do my best to not place any kind of mesh if I can avoid it....”
Participant 7	“…If they know that they’re going to want to have other children for sure, I give them the option then…Delaying hernia repair until after is usually my recommendation. Now 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.”
Patient preference
Participant 19	“…I would speak to her about open repair vs a laparoscopic repair vs robotic repair…I’d leave it up to her and give her the potential morbidities, mortalities for each of the repairs…I would tell her the risks…vs the benefits….”
Participant 20	“...I'll discuss with them the potential of delaying surgery until they are finished having children because of that risk of…stretching of the abdominal wall and potentially recurring…the hernia.”

Discussion

The current literature recommends delaying elective repair until after the last pregnancy, because pregnancy following hernia repair increases the risk of recurrence 1.6-fold.⁶ Mesh repair has been associated with a decreased recurrence rate.⁵ Despite these practice guidelines, variation in hernia practice in women and girls of childbearing age exists. This study identifies surgeon attitudes, beliefs, and motivations potentially driving this practice variation. Consideration of childbearing when evaluating potential operative interventions for female patients remains inconsistent, suggesting a lack of surgeon awareness or consensus.

Study limitations included the inability to correlate verbalized beliefs with actual practice patterns and a potential response bias for social acceptability (eg, participants stating that they consider childbearing intent because it seems expected to do so). We attempted to mitigate this risk by using nonsurgeon interviewers.

Ultimately, the variation in surgeon approach found in this study highlights the need for continued awareness of sex, childbearing age, and childbearing intent as variables in surgical decision-making. The study also emphasizes the importance of establishing and standardizing sex-specific factors through guidelines consensus when discussing hernia management options. Existing practice guidelines should contribute to the formation of an informed shared decision-making process, ensuring that decisions are tailored to each patient’s characteristics.

Supplement.

eAppendix. Interview Guide.