Is the attending the person who takes charge of the operation?

   So regardless of whether a student actually does the job, or
the I'm supposing much more experienced attending (attendant?
attender?) does the job, the cost is the same?

   Even if he doesn't do the surgery. From my ingnorant position,
it still seems that may not always be the case, but my entire education
about it so far is from you people having this discussion.

Step 1: go to http://www.guideline.gov/

Step 2: enter "inguinal hernia" in the search box.

Step 3: click the hotlink given for the SSAT guideline on
the surgical repair of groin hernias.  It's easy to do.  Your
search will only come up with that one guideline.

Step 4: read the guideline, which includes the following two
paragraphs verbatim:

Inasmuch as I don't subscribe to any surgical specialty journals
(and most of them are closed to non-subscribers, so offering a
link to articles from their archives wouldn't do much good) I
offer http://pmj.bmjjournals.com/cgi/reprint/77/905/188 as an
example of a recent study on the changes in inguinal hernia repair
over the past decade.  By "day case" the Brits mean "outpatient."

Inasmuch as all laparoscopic herniorrhaphies require general
anesthesia (you can get away with a spinal block or even a local
block for uncomplicated open repairs), this means that the over-
whelming majority of these outpatient surgeries involve the ad-
ministration of general anesthesia after which the patients - who
come to the surgical suite on the day of the procedure, and are
not admitted to the hospital beforehand - *still* go home to
that same afternoon to recuperate.  

Or do you mean something different by "those increased
hospital costs" you maunder about?  Most of my patients
in decent medical condition who require uncomplicated
inguinal herniorrhaphies get them performed at one or
another of the freestanding surgical centers scattered all
over the county next door.  Most of the cutters to whom
I refer don't like to bother with performing these procedures
in their offices, chiefly because the surgical centers are so
damned convenient in terms of location, support services,
and scheduling accessibility.  No goddam hospital politics
to put up with, either.  I've had ECF ("nursing home") patients
shuttled by an ambulance service from their room at the local
Snoozing Acres in the morning, surgerized first thing on the
schedule, and back at Snoozing Acres before the 3-to-11 shift
comes on.  

And just how the hell does one perform an open repair of any
type without considering which technique (I was taught to go
with a Bassini repair whenever practicable) to undertake?
Laparoscopic repairs are much more common now than they
were when I was ligating bleeders, but in certain cases you've
got not a helluva lot of choice.  I had to cope with a cadre of
general surgeons who had leaped on laparoscopic cholecystec-
tomies and herniorrhaphies with verve back in the '80s, but
although every one of them tried his/her best to handle ruptures
using their nifty new "ship in a bottle" technique, the scrub nurse
still had a full kit of carving equipment on the side table and ready
for use should they have to default to open repair.  

As for whether or not surgical residents practice on their
own, the ones who are *licensed* (for which they are el-
igible after completing the first year of postgraduate medical
education in most states) can and frequently do.  I got to
know a couple of fully licensed surgical and medical oncology
fellows out of Sloan-Kettering who were moonlighting on
Emergency Department coverage at the hospital where I
completed my internship, and when I was back at that same
hospital as a GP resident, I routinely took shifts in the ER -
and was paid for it - on my nights off.  Of course, between
completing my internship and starting my residency I did a
hitch in the U.S. Public Health Service, and served as medical
director of a Health Underserved Rural Area clinic (which
entailed a moderately heavy inpatient service and medical
call along with all the other primary care guys on staff).  

There's nothing to prevent a resident with a medical license
from practicing medicine. Back in the '60s and '70s, a lot of
guys either moonlighted (I also covered a couple of GP's prac-
tices on odd evenings) or did caritas work in the free clinics.  
Hell, I did free clinic work (under nominal supervision) as a
medical student.  I've also known both preceptors and contem-
porary colleagues who undertook fellowships in specialty areas
- two guys I know did that in dermatology - and one crusty old
S.O.B. I knew had done a dozen years in general practice before
he plugged into a radiology residency and got himself boarded
in Rays.  You can bet your life that *he* continued to practice
"on the side" all throughout his residency.  

In relatively uncomplicated cases, the participation of the
nominal attending surgeon or physician can be nominal indeed.
During my med school years and during postgraduate training,
for example, the attending obstetricians almost never saw the
uncomplicated clinic patients unless they were assigned to the
raw first-year residents.  All the OB/GYN chief residents on
the services were thoroughly salted, and pretty much ran the
day-to-day affairs of the department the way a good XO
handles the routine operations aboard a man of war.  Things
may be different in these ultralitigious times, but for all practical
purposes a cutter or baby-catcher in the final year of his/her
residency had better be able to handle him/herself as a reliably
independent decision-maker and capable physician.  Nobody
just waves a magic wand over the guy on 30 June and says:
"Now thou art qualified to become an Attending Physician!"  

And of course the attending surgeon will bill for services rendered.
A board-certified cutter will be paid more by CMS (formerly HCFA)
than a non-boarded guy will.  Back when I was young and hadn't
been burned out from the endless round of painful copulation with the
third-party payer porcupines, I certainly never received "reimburse-
ment" for the women I delivered as great as the obstetricians routine-
ly  did.  Between that and the "captain of the ship" principle (under
which the attending is drop-dead responsible for the outcome of
patient care rendered even under his/her nominal supervision), it's
inevitable that the provider number on the statement is likely to be-
long to someone the patient doesn't even recall meeting.  I've had to
explain that to patients and their families on more than one occasion.

Anent putative "spitballing," are you operating under the impression
that I'm *not* a physician?  Tsk.  Your ignorance is showing.  

----------
Hygiene is the corruption of medicine by morality.  It is
impossible to find a hygienist who does not debase his
theory of the healthful with a theory of the virtuous.  The
whole hygienic art, indeed, resolves itself into an ethical
exhortation.  This brings it, at the end, into diametrical
conflict with medicine proper.  The true aim of medicine
is not to make men virtuous; it is to safeguard and rescue
them from the consequences of their vices.  The physician
does not preach repentance; he offers absolution.

       -- H.L. Mencken, The Smart Set, May 1919

The exchange you're talking about is lower cost for a lesser quality of
surgery. Really now...think about that. Does that sound realistic in this
day when doctors around the world are criticized regularly for "medical
mistakes", and phone books and newspapers are crowded by ads for malpractice
lawyers? Medical students don't have malpractice insurance. Neither do
residents unless they are supervised by a qualified surgeon so designated.
That supervising surgeon is there to make sure that the quality of every
single operation done under their name is as good as it can be - he/she
stakes his/her reputation and the reputation of the institution where they
work on every single operation. You're talking about multiple standards of
care - better care if you can afford it, second-rate if you're poor. However
it works out in practice, opposition to that concept is a rallying cry (more
of a shriek, really) for watchdog groups all across the USA.

As to who is doing the operation -- we're not talking about heavy lifting
here....the attending surgeon gets paid by the patient to MAKE SURE that
their operation is done according to prevailing standards of care, for
taking that responsibility, and for imparting his/her experience and
knowledge to the extent necessary. Not for doing the physical work, which is
trivial in an energy-expenditure sense. I can assure you it is far more
stressful to teach someone to do an operation than it is to do one.

As to other questions you pose -- your friend's hernia will never get
smaller, only bigger. Strengthening the abdominl muscles won't help and are
far more likely to increase the size of the hernia, anything that increases
intraabdominal pressure such as straining will do so. Trusses -- they don't
cause scarring and do not make the operation more difficult in any way. They
don't fix the hernia, but do have the potential (in some cases) to decrease
the discomfort. If your friend isn't having pain, there's no point to
wearing a truss.

There are two problems with an inguinal hernia -- 1) causing the patient
discomfort  2) the possibility that the loop of intestine could become
trapped and strangled in the hernia sac (strangulated hernia). The
likelihood of such a strangulation is relatively low (although if it does
occur, it's a true emergency). If those two issues don't apply to your
friend, then the repair can certainly wait until he gets health insurance,
saves enough money, or can apply for some kind of medicaid-based program. In
the VA system of the US where health care is rationed, it would not
necessarily be uncommon for a patient to wait months or even years to get
his hernia operation. This is likewise true in at least a few industrialized
nations that have a nationalized health care program.

HMc