General surgeons are responsible for treating a vast array of surgical diseases, but two conditions—inguinal hernia and acute cholecystitis—are some of the most seen in practices throughout the world. Despite their prevalence, there are multiple approaches to management, and surgeons debated treatment for each condition during Tuesday’s Panel Session, The Great Debates – Biliary and Hernia.
Hernia
Ian T. MacQueen, MD, from the David Geffen School of Medicine at the University of California, Los Angeles, provided the “pro” argument for open inguinal hernia repair, discussing the commonly used Lichtenstein open repair technique versus two minimally invasive surgery (MIS) options—laparoscopic totally extraperitoneal (TEP) repair and robotic transabdominal preperitoneal repair (TAPP).
He argued that because there is no single treatment option that works for all patients, surgeons should focus on open repair as their foundational approach.
Open repair is the “operation that is indispensable to us as surgeons, to patients, and to society, while minimally invasive surgery is a ‘nice-to-have’ procedure that looks good, but the value just isn’t there,” Dr. MacQueen said.
He described open hernia repair’s strength in adaptability to patient populations, lower costs, no significant difference in hernia recurrence and potential for rare but serious morbidities, and the easier reproducibility of open repair through a lower learning curve for trainees.
On the other side, Arielle Perez, MD, MPH, FACS, from the University of North Carolina (UNC) at Chapel Hill, provided a “pro” perspective on MIS hernia repair, where she suggested that surgeons think about what their “go-to” technique should be for this common procedure and argued that it should be an MIS technique.
Dr. Perez summarized some of the positives of MIS hernia repair, including reduced postoperative pain, a faster return to activity, and similar OR time and complication rates, but she also discussed the value of MIS in providing a critical view of the myopectineal orifice (MPO).
The MPO view allows surgeons to rule out direct hernias, ensure adequate mesh coverage, and, importantly, it obligates a view of the femoral space to rule out femoral hernias, which is especially important for women.
“When you look at groin hernias in women, it’s kind of a DEI issue, and we want to make sure we’re taking care of our female patients. Up to 37% of groin hernias in women are femoral,” she noted, and these types of hernias can be present more morbidities than inguinal hernias.
Biliary
Michael T. LeCompte, MD, from UNC Health in Raleigh, opened the biliary debate by discussing the value of percutaneous cholecystostomy tubes (PCT) for managing acute cholecystitis.
The refinement of laparoscopic cholecystectomy has necessitated a close look at the effectiveness and need for PCT placement, Dr. LeCompte said, and he explained that the tubes are highly effective at resolving initial acute symptoms of cholecystitis and may delay or obviate the need for surgery in some cases.
However, “we need to realize there are two very different types of patients who present with cholecystitis—those who present with severe disease or sepsis derived from a biliary source, or those who are admitted with a different disease process who develop cholecystitis as a secondary process,” he said, and from there, a patient’s candidacy for surgery can be broken down into “yes,” “maybe,” and “never” buckets.
Cholecystitis may ultimately be necessary and advised for many patients, but Dr. LeCompte is pro-PCT placement for select groups of patients and would not abandon the management option.
The other side of the debate was argued by Mira Ghneim, MD, FACS, from the University of Maryland Medical System in Baltimore, who provided a “pro” position for managing acute cholecystectomy with laparoscopic cholecystitis (lap chole).
Dr. Ghneim described the quickly evolving surgical treatment paradigm for cholecystitis, especially in the last 10 years, which increasingly showed that lap chole is the recommended approach and that there is little evidence that PCT placement is effective.
She noted that there is no support from the literature comparing management of the high-risk gallbladder with lap chole against PCT, but there is extensive literature “comparing early versus delayed cholecystectomy—the nonoperative plus antibiotics approach—so if you are going to extrapolate that symptom duration means a more inflamed gallbladder and I should drain it, we know from literature that earlier [cholecystectomy] is better.”
While there may be a few very limited cases where she would place PCT, Dr. Ghneim said that lap chole has been unequivocally established as the gold standard of care for patients with acute cholecystectomy.
You can watch the entire session on the virtual platform to see audience polling questions on different scenarios related to hernia and cholecystitis management and rebuttals from each panelist to their respective counterparts.
