Study: No value in sending hernia sac specimens for routine pathology

Pathologic evaluations of hernia sac specimens from adult patients did not alter clinical management, and cost a medical center more than $75,000 over 4 years, according to a study published online in the American Journal of Surgery.

“The results from our study indicate that ‘routine’ evaluation of hernia sac specimens is likely neither indicated nor cost effective,” said Dr. Patrick Chesley of Madigan Army Medical Center, Fort Lewis, Wash., and his associates. “The rarity of changes in diagnosis and treatment from routine pathologic examination of a hernia sac does not justify this practice, and indicates that it may be omitted except in unique circumstances.”

The practice of sending hernia sac specimens for pathologic evaluation dates to 1926, when the American College of Surgeons Minimum Standard for Hospitals stated that all tissues removed during surgery should be examined and the results reported. The Joint Commission reiterated that recommendation in 1998, stating in its Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services that ‘‘specimens removed during surgery need to be evaluated for gross and microscopic abnormalities before a final diagnosis can be made.”

But the literature offers little support for the recommendation regarding hernia sac specimens, and institutions are starting to question the practice, Dr. Chesley and his associates wrote (Am. J. Surg. 2015 Feb. 12 [doi: 10.1016/j.amjsurg.2014.12.019]).

In one study, for example, pathologists reviewed 1,020 hernia sac specimens and found that only one had yielded an unexpected result – an atypical lipoma that did not affect patient management. Another study reviewed more than 2,000 hernia repairs and found that only 34% cases underwent pathologic review, with no resulting changes in treatment or management of any case.

For their study, Dr. Chesley and his coinvestigators retrospectively reviewed operative reports and medical records for 1,216 inguinal, incisional, umbilical, and ventral hernia repairs, all of which occurred at a single medical center between 2007 and 2011. More than half (55.4%) of cases were inguinal hernia repairs, 21.5% were umbilical, 11.4% were incisional, and 11.7% were ventral. In 20% of cases, surgeons sent hernia sac specimens for pathologic evaluation. Of these, 96% were selected for routine examination and 4% were selected because of concerns about possible gross abnormalities, the researchers said. Regardless of the reason for pathologic evaluation, none of the 246 examinations produced findings that reportedly altered clinical management, they said. Furthermore, pathologic evaluations cost patients about $300 to $350 each, for a total bill of more than $75,000 during the course of the study.

“These data reflect previous results from the pediatric surgical literature, and support the notion that routine pathologic evaluation of hernia sac specimens is not indicated,” the researchers concluded. But the recommendation should only apply to routine pathologic examinations, and surgeons should continue to treat abnormal intraoperative findings during hernia repair as indications for pathologic evaluation at their own discretion, they said.

Because the study was retrospective, the researchers could not ensure completeness of the data, they said. They also lacked a standardized method for reporting the reasons for specimen collection.

They reported no funding sources and declared no conflicts of interest.

Pathologic evaluations of hernia sac specimens from adult patients did not alter clinical management, and cost a medical center more than $75,000 over 4 years, according to a study published online in the American Journal of Surgery.

“The results from our study indicate that ‘routine’ evaluation of hernia sac specimens is likely neither indicated nor cost effective,” said Dr. Patrick Chesley of Madigan Army Medical Center, Fort Lewis, Wash., and his associates. “The rarity of changes in diagnosis and treatment from routine pathologic examination of a hernia sac does not justify this practice, and indicates that it may be omitted except in unique circumstances.”

The practice of sending hernia sac specimens for pathologic evaluation dates to 1926, when the American College of Surgeons Minimum Standard for Hospitals stated that all tissues removed during surgery should be examined and the results reported. The Joint Commission reiterated that recommendation in 1998, stating in its Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services that ‘‘specimens removed during surgery need to be evaluated for gross and microscopic abnormalities before a final diagnosis can be made.”

But the literature offers little support for the recommendation regarding hernia sac specimens, and institutions are starting to question the practice, Dr. Chesley and his associates wrote (Am. J. Surg. 2015 Feb. 12 [doi: 10.1016/j.amjsurg.2014.12.019]).

In one study, for example, pathologists reviewed 1,020 hernia sac specimens and found that only one had yielded an unexpected result – an atypical lipoma that did not affect patient management. Another study reviewed more than 2,000 hernia repairs and found that only 34% cases underwent pathologic review, with no resulting changes in treatment or management of any case.

For their study, Dr. Chesley and his coinvestigators retrospectively reviewed operative reports and medical records for 1,216 inguinal, incisional, umbilical, and ventral hernia repairs, all of which occurred at a single medical center between 2007 and 2011. More than half (55.4%) of cases were inguinal hernia repairs, 21.5% were umbilical, 11.4% were incisional, and 11.7% were ventral. In 20% of cases, surgeons sent hernia sac specimens for pathologic evaluation. Of these, 96% were selected for routine examination and 4% were selected because of concerns about possible gross abnormalities, the researchers said. Regardless of the reason for pathologic evaluation, none of the 246 examinations produced findings that reportedly altered clinical management, they said. Furthermore, pathologic evaluations cost patients about $300 to $350 each, for a total bill of more than $75,000 during the course of the study.

“These data reflect previous results from the pediatric surgical literature, and support the notion that routine pathologic evaluation of hernia sac specimens is not indicated,” the researchers concluded. But the recommendation should only apply to routine pathologic examinations, and surgeons should continue to treat abnormal intraoperative findings during hernia repair as indications for pathologic evaluation at their own discretion, they said.

Because the study was retrospective, the researchers could not ensure completeness of the data, they said. They also lacked a standardized method for reporting the reasons for specimen collection.

They reported no funding sources and declared no conflicts of interest.

Pathologic evaluations of hernia sac specimens from adult patients did not alter clinical management, and cost a medical center more than $75,000 over 4 years, according to a study published online in the American Journal of Surgery.

“The results from our study indicate that ‘routine’ evaluation of hernia sac specimens is likely neither indicated nor cost effective,” said Dr. Patrick Chesley of Madigan Army Medical Center, Fort Lewis, Wash., and his associates. “The rarity of changes in diagnosis and treatment from routine pathologic examination of a hernia sac does not justify this practice, and indicates that it may be omitted except in unique circumstances.”

The practice of sending hernia sac specimens for pathologic evaluation dates to 1926, when the American College of Surgeons Minimum Standard for Hospitals stated that all tissues removed during surgery should be examined and the results reported. The Joint Commission reiterated that recommendation in 1998, stating in its Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services that ‘‘specimens removed during surgery need to be evaluated for gross and microscopic abnormalities before a final diagnosis can be made.”

But the literature offers little support for the recommendation regarding hernia sac specimens, and institutions are starting to question the practice, Dr. Chesley and his associates wrote (Am. J. Surg. 2015 Feb. 12 [doi: 10.1016/j.amjsurg.2014.12.019]).

In one study, for example, pathologists reviewed 1,020 hernia sac specimens and found that only one had yielded an unexpected result – an atypical lipoma that did not affect patient management. Another study reviewed more than 2,000 hernia repairs and found that only 34% cases underwent pathologic review, with no resulting changes in treatment or management of any case.

For their study, Dr. Chesley and his coinvestigators retrospectively reviewed operative reports and medical records for 1,216 inguinal, incisional, umbilical, and ventral hernia repairs, all of which occurred at a single medical center between 2007 and 2011. More than half (55.4%) of cases were inguinal hernia repairs, 21.5% were umbilical, 11.4% were incisional, and 11.7% were ventral. In 20% of cases, surgeons sent hernia sac specimens for pathologic evaluation. Of these, 96% were selected for routine examination and 4% were selected because of concerns about possible gross abnormalities, the researchers said. Regardless of the reason for pathologic evaluation, none of the 246 examinations produced findings that reportedly altered clinical management, they said. Furthermore, pathologic evaluations cost patients about $300 to $350 each, for a total bill of more than $75,000 during the course of the study.

“These data reflect previous results from the pediatric surgical literature, and support the notion that routine pathologic evaluation of hernia sac specimens is not indicated,” the researchers concluded. But the recommendation should only apply to routine pathologic examinations, and surgeons should continue to treat abnormal intraoperative findings during hernia repair as indications for pathologic evaluation at their own discretion, they said.

Because the study was retrospective, the researchers could not ensure completeness of the data, they said. They also lacked a standardized method for reporting the reasons for specimen collection.

They reported no funding sources and declared no conflicts of interest.