Since the introduction of polypropylene (PP) mesh for hernia repair, surgeons continue to discuss the use of mesh in a variety of settings for one of the most common operations performed by general surgeons—hernia repair. This discussion has involved raw materials, cost, and outcomes and for many years referred to only a few products, as manufacturing was limited. Nowadays, with multiple permanent, absorbable, biologic, and hybrid products on the market, the choice of mesh for a hernia repair can be daunting. Increasing clinical complexity further emphasizes the need for individualizing care, but more frequently, hospital supply chain personnel institute product procurement procedures for cost control, limiting mesh choice for surgeons. This can force surgeons into a “one-size-fits-all” practice regarding mesh choice, which may not be ideal for some patients. Conversely, current literature lacks definitive evidence supporting the use of one mesh over another, a fact that has not escaped the radar screen of the hospital supply chain and mesh industry, both of which attempt to limit vendor and mesh choice for financial gain. It is unlikely that this type of “proof” will ever come to fruition. This leaves us with choosing a mesh based on an algorithm that is centered on the patient and the patient’s unique clinical scenario.
Surgical stereotypes are remnants of the days of pre-anaesthesia surgery and include impulsivity, narcissism, authoritativeness, decisiveness, and thinking hierarchically. Medical students hold these stereotypes of surgeons early in their medical training. As Pearl Katz says in the The Scalpel’s Edge: ‘Each generation perpetuates the culture and passes it on by recruiting surgical residents who appear to resemble them and training these residents to emulate their thinking and behaviour.’ The culture of surgery has evolved, and certain behaviours are rightly no longer seen as acceptable, Non-technical skills such as leadership and communication have become incorporated into surgical training. Wen Shen, Associate Professor of Clinical Surgery at University of California San Francisco, argues that this has gone too far: ‘Putting likeability before surgical outcomes is like judging a restaurant by the waiters and ignoring the food,’ I would argue that operative and communication skills are indivisible, An aggressive surgeon is a threat to patient safety if colleagues are frightened to speak up for fear of a colleague shouting or, worse, throwing instruments. Conversely, a flattened hierarchy promotes patient safety.