In a recent article published in the Daily Telegraph, the president of the Royal College of Surgeons has stirred up a mini-controversy. He suggested that policies of not operating on patients for planned procedures who have problems such as obesity and/or who smoke were “draconian and discriminatory”. This drew a response from Mr Windsor on behalf of the British Hernia Society. Mr Windsor stated that “The key to good surgical outcomes is to understand patients and tailor surgery to their needs. Part of that process involves optimizing their health and clinical condition”
What are the risk factors?
There is plenty of evidence about risk factors for hernia surgery. Smoking, obesity, and diabetes are probably the most significant.
Many UK plastic surgeons had a policy not to carry out elective, non-cancer operations in patients who continue to smoke because of the increased risk of complications. Most other surgical specialties have not taken the same stance despite there being evidence of poorer outcomes in those patients who do continue to smoke.
Obesity is also associated with poorer surgical outcomes in hernia patients. The surgery can be more challenging. There are also greater risks of general postoperative complications such as wound infection or breakdown as well as recurrent herniation.
The numbers of patients suffering from diabetes are increasing. For many, the development of diabetes is directly related to diet and obesity. There is good evidence that dietary control leading to weight loss can improve diabetes and diabetic control. Patients with diabetes are more likely to develop complications following hernia surgery. Better control of diabetes before an operation is associated with fewer risks of complications.
Nobody would deny a patient an urgent or emergency operation based on whether or not they smoke, are overweight or have diabetes. These patients need an operation often to save life or prevent a more serious complication. In these circumstances, we can accept the additional risks that their smoking habits, obesity or diabetes may bring.
But if we have the chance to reduce those risks before an elective or planned hernia operation we should do so. The burden of a potentially preventable complication from a planned operation may be considerable not only for the patient but for their surgeon as well.
Is it fair for us to simply say “go away, lose weight or stop smoking before we operate”?.
If we do so we must also give advice to patients about the issues and the risks that may ensue. We should also help patients with achieving weight loss, stopping smoking and getting tight diabetic control. This could be through a targeted weight reduction program, a smoking cessation program or with the help of GP. There’s a lot that can be achieved. If followed the effects should go beyond reducing the immediate risk of postoperative complication. They will be translated into a longer and healthier life too.