High volume hernia surgery in specialist hernia centres

Hernia repair is one of the most common general surgical procedures worldwide. Despite the apparent simplicity of some of the more common hernia procedures, outcomes can vary widely depending on who performs the operation and where it is performed. Increasingly, there is a growing body of evidence supporting the centralisation of complex and even routine Hernia repairs to high-volume surgeons operating within specialist centres. Concentrating hernia surgery in such environments improves patient outcomes and experience and optimises healthcare resources and costs whilst sustaining innovation and training.

The volume–outcome relationship in hernia surgery

Decades of research have demonstrated a robust correlation between surgical volume and patient outcomes for many of the complex procedures such as pancreatic, oesophageal and aortic surgery.

Hernia surgery is no exception. There is large volume of research that demonstrates that volume also matters in simple hernia surgery. High-volume surgeons, defined as those performing 50 to 100 similar procedures annually, consistently achieve shorter operative times, lower complications such as chronic pain, fewer recurrences, and better functional outcomes compared to low-volume counterparts.

High-volume hernia surgeons develop not only technical proficiency but also the situational awareness to:

• manage unusual and difficult anatomy;
• anticipate complications, and;
• tailor repairs to individual patient and hernia characteristics.

For hernia varying from the simple to the more complex repairs, the learning curve is substantial. Approach (open vs. laparoscopic vs. robotic), dissection planes, mesh selection, choice of anaesthetic (local vs general), pain management, selection of imaging modalities and the varying the approach for different sizes of hernia defects, tissue quality and to each individual patient requires nuanced technical judgment and access to a multi-disciplinary team.

Why specialist centres

High-volume hernia surgeons rarely work in isolation. They operate within specialist centres where infrastructure, peers, multidisciplinary support, and culture all promote excellence. These centres typically feature:

• Dedicated hernia units with advanced imaging, operative technology, and multidisciplinary input including plastic surgeons.
• Specialised perioperative teams, including anaesthetists, physiotherapists, and specialist nurses familiar with hernia care pathways.
• Standardised pathways and protocols for patient experience, pain management, and enhanced recovery after surgery.
• Outcomes tracking via audit systems that drive continuous quality improvement.

Such centres provide infrastructure and resources for providing high-quality care to all patients with all types of hernias and varying the surgical and anaesthetic techniques to accommodate the wide variability in patient and hernia complexity. Complex decision making often exceeds the expertise or available resources in smaller, generalist hospitals. Centralising hernia surgery ensures that every patient, whether presenting with a routine inguinal hernia or a large recurrent incisional defect, benefits from the collective experience and expertise in a hernia centre.

Advantages to high volume surgeons and specialist centres

These are three-fold, which are consistent with the cornerstones of high-quality healthcare, improved patient outcomes and experience at lowered costs.

1.    Reduced short- and long-term outcomes

The most tangible benefit of high-volume, specialist-led hernia surgery is better patient outcomes. Recurrence, chronic pain, and infection remain the major causes of postoperative morbidity. Numerous national registry studies (e.g., Danish and Swedish) demonstrate that these risks decline significantly when repairs are performed by hernia specialists.

For example, inguinal hernia repair requires familiarity with identification and sparing of nerves and dissection around the cord structures. Inexperienced surgeons have higher rates of nerve and testicular artery injury and recurrence rates. Similarly, complex incisional hernias demand advanced understanding of abdominal wall reconstruction principles, which are rarely mastered by low-volume generalists. By entrusting all hernia repairs - including primary, recurrent, and complex - to high-volume specialists, the overall standard of care rises, and the costly burden of post-operative morbidity, expensive imaging and reoperations diminishes.

2.    Improved patient experience

Patients treated in specialist centres consistently report higher satisfaction levels. This reflects not only better clinical outcomes but also superior information, counselling, consent, and shared decision-making. High-volume surgeons have often mastered the full spectrum of hernias and can personalise the surgical and anaesthetic approaches to each individual patient’s condition. They discuss realistic expectations for recovery, complications, activity resumption, and long-term prognosis without causing unnecessary alarm and concern whilst at the same time highlighting the possibility of complications and delayed recovery for the more complex and challenging cases.

Moreover, specialist centres offer access to anaesthetic techniques such as nerve blocks and sedation and surgical techniques such as minimally invasive surgery that may not be available elsewhere, allowing patients to choose the approach best aligned with their preferences and lifestyle.

Centralisation thus enhances both the technical and humanistic aspects of surgical care.

The counterargument against specialisation and centralisation is related to patient travel and inequity for the most vulnerable populations. However, patient pathways that include protocols, specialist peri-operative teams, IT systems, e-mail/text messaging, scheduling flexibility due to high volume daily operating lists, telemedicine and remote patient monitoring, including patient reported outcomes (PROMs), can reduce patient travel to just the surgical episode of care. Patients can travel across the country to specialist centres to access the best outcomes and despite the travel, experience high quality personalised and convenient care in the pre- and post-operative phases.

3.    Cost-effectiveness

Hernia surgery is a good exemplar of value-based healthcare where payors, providers and patients are all aligned in achieving the best short- and long-term outcomes within a cost-effective system. At first glance, surgery in specialist centres may be associated with higher costs due to concentration of expertise, resources and technology. However, when viewed from a whole-systems perspective, the approach is highly cost-effective. Better pathways and protocols mean fewer hospital attendances and shorter hospital stays, lower complications mean less need for hospital-based resources and lower recurrence rates mean fewer reoperations.

High-quality initial repair saves money in the long term. Hernia complications can double or triple the lifetime cost of care for an individual patient. Moreover, specialist centres tend to have:

• streamlined processes and economies of scale;
• dedicated hernia lists;
• day-case pathways;
• remote patient follow-up protocols including patient-initiated follow-up.

They all enhance throughput and efficiency whilst maintaining safety and quality.

For health systems and payors under financial pressure, reducing access to hernia surgery to reduce healthcare costs is against patient welfare and is a case of pushing the can down the road, except the can gets bigger. There is abundant evidence that all hernias, including the simplest ones, need repairing at some point. They only get larger and with patients also developing other medical conditions with passing age, the costs of a deferred repairs will be greater.

Rather than focussing on short-term costs savings, healthcare systems should be focussing on enhancing value through reducing variation in patient outcomes through centralisation. This has already demonstrated in other more complex conditions like cancer and cardio-vascular disease.

Hernia surgery is no different. Referrals to high-volume specialist centres reduces the “hidden costs” associated with low-quality primary repairs performed by low volume inexperienced surgeons working in generalist hospitals. Moreover, professional and financial satisfaction through high volume work, removes any a perverse financial incentive to undertake unnecessary and often ill-suited investigations and surgical repairs in patients with conditions that need an alternate management approach and not surgery.

Other advantages

-       Innovation

Concentrating hernia surgery in specialist centres also sustains surgical innovation. Specialist centres provide the case volume for conducting trials and the insights for generating new ideas. Many of the advances in patient pathways, mesh technology, and minimally invasive approaches originated in specialist centres. Furthermore, the presence of established patient monitoring and audit systems in specialist centres provides invaluable data for academic publications and disseminating knowledge of specialist techniques.

-       Training

Specialist centres are also more likely to attract motivated trainees who can train in a range of conditions and surgical techniques varying from open to minimally invasive surgery in a short period of time. They provide high volume case exposure to even the rarer hernias, and enable the mentoring relationships that extend beyond the period of time spent in the training centre.