Annual Surgeon Volume and Patient Outcomes Following Laparoscopic Totally Extraperitoneal Inguinal Hernia Repairs

Laparoscopic totally extraperitoneal hernia repair in patients with a history of previous abdominopelvic surgery

A retrospective cohort study of patients undergoing laparoscopic inguinal hernia repair compared short- and long-term outcomes between individuals with or without history of previous abdominopelvic surgery, aiming to determine the feasibility of totally extraperitoneal (TEP) repair within this population. All patients who underwent elective TEP inguinal hernia repair by one consultant surgeon across three London hospitals from January 2017 to May 2023 were retrospectively analysed to assess perioperative outcomes. Two hundred sixty-two patients were identified, of whom two hundred forty-three (93%) underwent laparoscopic TEP repair. The most frequent complications were haematoma (6.2%) and seroma (4.1%). Recurrence occurred in four cases (1.6% of operations, 1.1% of hernias). One hundred eighty-four patients (76%) underwent day-case surgery. There were no mesh infections or explanations, vascular or visceral injuries, port-site hernias, damage to testicle, or persisting numbness. There were no requirements for blood transfusion, returns to theatre, or readmissions within 30 days. There was one conversion to open and one death within 60 days of surgery. Eighty-three (34%) had a history of previous AP surgery. There was no significant difference in perioperative outcomes between the AP and non-AP arms. This finding carried true for subgroup analysis of 44 patients whose AP surgical history did not include previous inguinal hernia repair and for those undergoing repair of recurrent hernia. In expert hands, laparoscopic TEP repair is associated with excellent outcomes and low rates of long-term complications, and thus should be considered as standard for patients regardless of a history of AP surgery.

Factors associated with conversion from day-case to in-patient elective inguinal hernia repair surgery across England: an observational study using administrative data

PURPOSE

Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, some patients planned for day-case surgery have to stay in hospital for at least one night. The aim of this study was to identify the factors associated with conversion from day-case to in-patient management for elective inguinal hernia repair surgery.

METHODS

This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 that was planned as day-case surgery were identified. The exposure of interest was discharged on the day of admission (day-case) or requiring overnight stay. The primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level.

RESULTS

A total of 351,528 planned day-case elective primary inguinal hernia repairs were identified over the eight-year study period. Of these, 45,305 (12.9%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions. Patients who converted to in-patient stay were older, had more comorbidities, and were more likely to have bilateral surgery and be operated on by a low-annual volume surgeon. Post-procedural complications were strongly associated with conversion. Across the 42 ICBs in England, model-adjusted conversion rates varied from 3.3% to 21.3%.

CONCLUSIONS

There was considerable variation in conversion to in-patient stay rates for inguinal hernia repair across ICBs in England. Our findings should help surgical teams to better identify patients suitable for day-case inguinal hernia repair and plan discharge services more effectively. This should help to reduce the variation in conversion rates.

Lower reoperation rates after open and laparoscopic groin hernia repair when performed by high-volume surgeons: a nationwide register-based study

PURPOSE

Previous studies have shown a correlation between surgeons with high annual volume and better outcomes after various surgical procedures. However, the preexisting literature regarding groin hernia repair and annual surgeon volume is limited. The aim was to investigate how annual surgeon volume affected the reoperation rates for recurrence after primary groin hernia repair.

METHODS

This nationwide cohort study was based on data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. Patients ≥ 18 years undergoing laparoscopic or Lichtenstein primary groin hernia repair between November 2011 and January 2020 were included. Annual surgeon volume was divided into five categories: ≤ 10, 11-25, 26-50, 51-100, and > 100 cases/year.

RESULTS

We included 25,262 groin hernia repairs performed in 23,088 patients. The risk of reoperation for recurrence after Lichtenstein repair was significantly higher for the volume categories of ≤ 10 (HR 4.02), 11-25 (HR 3.64), 26-50 (HR 3.93), or 51-100 (HR 4.30), compared with the > 100 category. The risk of reoperation for recurrence after laparoscopic repair was significantly increased for the volume categories of ≤ 10 (HR 1.89), 11-25 (HR 2.08), 26-50 (HR 1.80), and 51-100 (HR 1.58) compared with the > 100 category.

CONCLUSION

The risk of reoperation for recurrence was significantly higher after Lichtenstein and laparoscopic repairs performed by surgeons with < 100 cases/year compared with > 100 cases/year. This indicates that higher surgeon volume minimizes the risk of reoperation for recurrence after groin hernia repair.

Lower recurrence rate after groin and primary ventral hernia repair performed by high-volume surgeons: a systematic review

PURPOSE

Hernia repair is a common procedure; however, an overview is lacking regarding the impact of annual surgeon volume and total surgical experience on the outcome of hernia repair. We aimed to explore the impact of annual surgeon volume and total surgical experience on outcomes of groin and primary ventral hernia repair.

METHODS

This systematic review followed the Prefered Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. A protocol was registered at PROSPERO (CRD42020176140). PubMed, EMBASE, and Cochrane CENTRAL were searched. We investigated recurrence rates after groin and primary ventral hernia repair reported according to annual surgeon volume or total surgical experience with at least 6 months follow-up. Surgeons were pooled in three overlapping categories: high-volume (> 50 cases/year), medium-volume (11-50 cases/year) and low-volume (≤ 25 cases/year).

RESULTS

Ten records for groin hernia and one for primary ventral hernia were included. The median (range) recurrence rates after laparoscopic groin hernia repair for high, medium, and low-volume surgeons were 2.6% (2.3-3.0), 2.4% (0.7-4.6), and 4.2% (1.0-6.8), respectively. The median (range) recurrence rate after open groin hernia repair for high, medium, and low-volume surgeons were 2.1% (2.0-2.2), 1.7% (1.6-2.3), and 2.4% (2.2-5.0). The groin hernia recurrence rate seemed to increase when annual surgeon volume decreased below 25 cases/year. For primary ventral hernia, increased annual surgeon volume was associated with decreased reoperation rate.

CONCLUSION

High-volume surgeons seemed to have lower rates of hernia recurrence after groin as well as primary ventral hernia repair and our data supports the need for centralization of groin hernia repair on individual surgeons.

Essentials in Minimally Invasive Gynecology Manual Skills Construct Validation Trial

Structured laparoscopic and hysteroscopic manual skills testing distinguished novice from mid-level residents, and board-certified obstetrician–gynecologists from fellowship-trained minimally invasive gynecologic surgeons.

To establish validity evidence for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems.

[Elective treatment of inguinal hernia in university surgery-an economic challenge]

INTRODUCTION

Elective and emergency inguinal hernia surgery is a central task for general and abdominal surgeons. As a standard procedure it is regarded as having a relatively low income in the German diagnosis-related groups (DRG) system. This can lead to an economic imbalance, especially in a cost-intensive environment of a university hospital. The aim of this analysis was to investigate the influence of clinical factors on costs and the contribution margin as well as the overall economic evaluation of elective inguinal hernia surgery at a university hospital.

MATERIAL AND METHODS

All patients undergoing elective inguinal hernia surgery at two locations of the Charité University Medicine Berlin in 2014 and 2015 were included in the analysis. The influence of clinical, patient and surgical factors on the economic outcome of the cases was evaluated.

RESULTS

A total of 419 patients were included, mostly after a Lichtenstein operation (44.9%) and laparoscopic transabdominal preperitoneal (TAPP) surgery (53.9%). The greatest impact on the economic outcome was the occurrence of postoperative complications. Also, a patient clinical complexity level (PCCL) value of >1, more than 8 encoded secondary diagnoses and a duration of hospital stay of less than 2 days had a significantly negative impact on the contribution margin. Overall, elective inguinal hernia surgery led to a negative contribution margin of € 651 per case.

CONCLUSION

Elective inguinal hernia surgery in the environment of a university hospital has a high financial deficit; however, since a complete discontinuation of this treatment is not an alternative multifactorial approaches are required to improve the economic outcome.

Hospital volume and outcome in inguinal hernia repair: analysis of routine data of 133,449 patients

Introduction

Inguinal hernias are repaired using either open or minimally invasive surgical techniques. For both types of surgery it has been demonstrated that a higher annual surgeon volume is associated with a lower risk of recurrence. This present study investigated the volume-outcome implications for recurrence operations, surgical complications, rate of chronic pain requiring treatment, and 30-day mortality based on the hospital volume.

Materials and methods

The data basis used was the routine data collected throughout the Federal Republic of Germany for persons insured by the Local General Sickness Fund “AOK” who had undergone inpatient inguinal hernia repair between 2013 and 2015. Complications were recorded by means of indicators. Hospitals were divided into five groups on the basis of the annual caseload volume: 1–50, 51–75, 76–100, 101–125, and ≥ 126 inguinal hernia repairs per year. The effect of the hospital volume on the indicators was assessed using multiple logistic regression.

Results

133,449 inguinal hernia repairs were included. The incidence for recurrence operations was 0.95%, for surgical complications 4.22%, for chronic pain requiring treatment 2.87%, and for the 30-day mortality 0.28%. Low volume hospitals (1–50 and 51–75 inguinal hernia repairs per year) showed a significantly increased recurrence risk compared to high volume hospitals with ≥ 126 inguinal hernia repairs per year (odds ratio: 1.53 and 1.24). No significant correlations were found for the other results.

Conclusions

The study gives a detailed picture of hospital care for inguinal hernia repair in Germany. Furthermore, it was noted that the risk of hernia recurrence decreases in line with a rising caseload of the treating hospital.

TEP for elective primary unilateral inguinal hernia repair in men: what do we know?

INTRODUCTION

Based on the new international guidelines for groin hernia management, there is no one surgical technique that is suited to all patient characteristics and diagnostic findings. Therefore, a tailored approach should be used. Here, a distinction must be made between primary unilateral inguinal hernia in men and in women, bilateral inguinal hernia, scrotal inguinal hernia, inguinal hernia following pelvic and lower abdominal procedures, patients with severe cardiopulmonary complications, recurrent inguinal hernias and incarcerated inguinal and femoral hernias. This paper now explores the relevant studies on TEP for elective primary unilateral inguinal hernia in men, which constitutes the most common indication for repair.

MATERIAL

A systematic search of the available literature was performed in February 2019 using Medline, PubMed, Scopus, Embase, Springer Link and the Cochrane Library. Only meta-analyses, systematic reviews, RCTs and comparative registry studies were considered. 117 publications were identified as relevant.

RESULTS

RCTs and comparative registry analyses demonstrated the advantages of TEP with regard to postoperative complications, complication-related reoperations, and postoperative and chronic pain compared with Lichtenstein repair for elective primary unilateral inguinal hernia repair in men. No relevant differences were found compared with TAPP. Mesh fixation is not needed in TEP, but heavyweight meshes result in a lower recurrence rate. Extraperitoneal bupivacaine analgesia vs placebo does not demonstrate any advantages, but drainage is advantageous for seroma prophylaxis. The risk of chronic pain is negatively influenced by small defects, younger patient age, preoperative pain, higher BMI, postoperative complications, higher ASA score and risk factors.

CONCLUSION

For the subgroup of elective primary unilateral inguinal hernia in men, accounting for a proportion of less than 50% of the total collective, advantages were identified for TEP compared with open Lichtenstein repair but not versus TAPP.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project

INTRODUCTION

There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems.

METHODS

The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries.

RESULTS

The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center.

CONCLUSION

Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

Hand Surgeons Performing More Open Carpal Tunnel Releases Do Not Show Better Patient Outcomes

BACKGROUND

Although previous studies have shown that more experienced surgeons have better patient outcomes following a variety of procedures, in hand surgery and carpal tunnel release in particular, this relation remains unproven. The authors assessed whether there is an association between surgeon volume and patient outcomes following open carpal tunnel release.

METHODS

Patients who underwent carpal tunnel release between 2011 and 2015 at outpatient hand surgery clinics in The Netherlands were included. Surgeon annual volume was defined as the average number of carpal tunnel releases performed per year per participating surgeon over the study period. Primary outcome measures were the Symptom Severity Scale and Functional Status Scale of the Boston Carpal Tunnel Questionnaire 6 months postoperatively. Multilevel random intercept linear regression analyses were performed to assess whether there was an association between surgeon annual volume and outcome measures, with adjustment for patient characteristics, concomitant procedures, and intake score on the Boston Carpal Tunnel Questionnaire.

RESULTS

A total of 1345 patients were included, operated on by 17 surgeons. Median annual surgeon volume was 75 (interquartile range, 50 to 149). Only 0.5 to 0.6 percent of the total variance in patient outcome on the Boston Carpal Tunnel Questionnaire could be explained by random differences between surgeons. The authors did not find an association between annual surgeon volume and outcome measures 6 months postoperatively (Symptom Severity Scale: β = 0.000; 95 percent CI, -0.001 to 0.001; and Functional Status Scale: β = 0.000; 95 percent CI, -0.001 to 0.001).

CONCLUSION

In the authors' sample of highly specialized hand surgeons operating in high-volume centers, they found no differences in outcome between high- and low-volume surgeons.

Predictors of laparoscopic versus open inguinal hernia repair

BACKGROUND

Inguinal hernia repair (IHR) is among the most common general surgery procedures. Multiple studies have examined costs and benefits of laparoscopic approach versus open repair. This study aimed to identify patient, surgeon, and hospital demographic predictors of laparoscopic versus open IHR.

METHODS

We conducted a retrospective analysis of 342,814 IHRs (241,669 open; 101,145 laparoscopic) performed in adults (age ≥ 18) from 2010 to 2015 using the Premier Hospital Database. Multivariate logistic regression was used to estimate the adjusted odds ratio of an IHR being laparoscopic versus open with respect to several demographic variables.

RESULTS

The odds of an IHR being laparoscopic increased from 2010 to 2015. A laparoscopic procedure was more likely in patients who were < age 65 (OR 1.29, CI 1.24-1.31, p < 0.0001), male (OR 1.31, CI 1.27-1.34, p < 0.0001), privately insured (OR 1.36, CI 1.33-1.40, p < 0.0001), and neither white, black, nor Hispanic (OR 1.11, CI 1.09-1.14, p < 0.0001). The likelihood of a procedure being laparoscopic decreased 13% with each one-unit increase in Charlson comorbidity index value (OR 0.88, CI 0.87-0.89, p < 0.0001). Surgeons were more likely to perform a laparoscopic procedure if they had larger annual IHR caseloads (≥ 45/year; OR 1.57, CI 1.53-1.60, p < 0.0001), and operated at large hospitals (> 500 beds; OR 1.36, CI 1.33-1.39, p < 0.0001) in New England (OR 2.38, CI 2.29-2.47, p < 0.0001). Non-predictors of a laparoscopic procedure included urban/rural hospital location (OR 1.02, CI 0.10-1.05, p = 0.06) and hospital teaching status (OR 1.01, CI 0.99-1.03, p = 0.2084).

CONCLUSIONS

Use of laparoscopic IHR is increasing. Patient age, gender, race, and insurance type, as well as surgeon annual volume, hospital size, and hospital region were predictors of a laparoscopic procedure. Further studies are needed to explain and remedy underlying differences impacting these predictors.

What Is the Influence of Simulation-Based Training Courses, the Learning Curve, Supervision, and Surgeon Volume on the Outcome in Hernia Repair?-A Systematic Review

Introduction: In hernia surgery, too, the influence of the surgeon on the outcome can be demonstrated. Therefore the role of the learning curve, supervised procedures by surgeons in training, simulation-based training courses and surgeon volume on patient outcome must be identified. Materials and Methods: A systematic search of the available literature was carried out in June 2018 using Medline, PubMed, and the Cochrane Library. For the present analysis 81 publications were identified as relevant. Results: Well-structured simulation-based training courses was found to be associated with a reduced perioperative complication rate for patients operated on by trainees. Open as well as, in particular, laparo-endoscopic hernia surgery procedures have a long learning curve. Its negative impact on the patient can be virtually eliminated through consistent supervision by experienced hernia surgeons. However, this presupposes availability of an adequate trainee caseload and of well-trained hernia surgeons and calls for a certain degree of centralization in hernia surgery. Conclusion: Training courses, learning curve, supervision, and surgeon volume are important aspects in training and outcomes in hernia surgery.

Cadaveric Dissection vs Homemade Model: What is the Best Way to Teach Endoscopic Totally Extraperitoneal Inguinal Hernia Repair?

BACKGROUND

Endoscopic totally extraperitoneal inguinal hernia repair (TEP-IHR) requires practice and training to perform well. We developed a simple, low-cost, inanimate model to teach surgical residents inguinal anatomy and the technique of mesh insertion for a safe, endoscopic TEP-IHR. The objective of this study was to compare our model vs cadaveric dissection for teaching anatomy and mesh insertion.

METHODS

A total of 14 general surgery residents participated in an institutional review board approved, prospective, and randomized study. Participants received a timed, web-based, interactive pretest assessing relevant anatomy and operative-based techniques. They then performed endoscopic TEP-IHRs on either a cadaver or our low-cost model. Participants then received a timed, web-based interactive posttest consisting of the same questions. Participants were surveyed anonymously regarding the degree to which either the model or the cadaver was educationally effective.

RESULTS

Both groups of trainees (cadaver = 7, low-cost model = 7) scored higher on the posttest (p<0.05) with similar improvement (cadaver group: pretest = 78% correct, posttest = 87%; low-cost model group: 77% vs 86%). Survey results revealed the trainees preferred for both initial learning and understanding of mesh placement using low-cost models (5 out of 5, 4.8/5, respectively) over cadavers (4.0/5, 3.8/5, respectively; p<0.05). Trainees preferred the cadaver (4.7) over the low-cost model (3.9, p<0.05) in overall experience. No differences were found in the trainees' preference between the cadaver (4.5) and low-cost model (4.7) in the overall educational value.

CONCLUSION

While the overall educational experience of 14 learners favored a cadaver experience to learn TEP-IHR, initial anatomical learning and placing the mesh was better with an inanimate model. Given the educational value of the 2 methods was equivalent, the $1500 cost for cadavers make the inexpensive and repeatable inanimate model an attractive early resource for learning TEP-IHR.

Does surgeon volume matter in the outcome of endoscopic inguinal hernia repair?

INTRODUCTION

For open and endoscopic inguinal hernia surgery, it has been demonstrated that low-volume surgeons with fewer than 25 and 30 procedures, respectively, per year are associated with significantly more recurrences than high-volume surgeons with 25 and 30 or more procedures, respectively, per year. This paper now explores the relationship between the caseload and the outcome based on the data from the Herniamed Registry.

PATIENTS AND METHODS

The prospective data of patients in the Herniamed Registry were analyzed using the inclusion criteria minimum age of 16 years, male patient, primary unilateral inguinal hernia, TEP or TAPP techniques and availability of data on 1-year follow-up. In total, 16,290 patients were enrolled between September 1, 2009, and February 1, 2014. Of the participating surgeons, 466 (87.6 %) had carried out fewer than 25 endoscopic/laparoscopic operations (low-volume surgeons) and 66 (12.4 %) surgeons 25 or more operations (high-volume surgeons) per year.

RESULTS

Univariable (1.03 vs. 0.73 %; p = 0.047) and multivariable analysis [OR 1.494 (1.065-2.115); p = 0.023] revealed that low-volume surgeons had a significantly higher recurrence rate compared with the high-volume surgeons, although that difference was small. Multivariable analysis also showed that pain on exertion was negatively affected by a lower caseload <25 [OR 1.191 (1.062-1.337); p = 0.003]. While here, too, the difference was small, the fact that in that group there was a greater proportion of patients with small hernia defect sizes may have also played a role since the risk in that group was higher. In this analysis, no evidence was found that pain at rest [OR 1.052 (0.903-1.226); p = 0.516] or chronic pain requiring treatment [OR 1.108 (0.903-1.361); p = 0.326] were influenced by the surgeon volume. As confirmed by previously published studies, the data in the Herniamed Registry also demonstrated that the endoscopic/laparoscopic inguinal hernia surgery caseload impacted the outcome. However, given the overall high-quality level the differences between a "low-volume" surgeon and a "high-volume" surgeon were small. That was due to the use of a standardized technique, structured training as well as continuous supervision of trainees and surgeons with low annual caseload.

Development of a standardized curriculum concept for continuing training in hernia surgery: German Hernia School

INTRODUCTION

The increasingly more complex nature of hernia surgery means that training programs for young surgeons must now meet ever more stringent requirements. There is a growing demand for improved structuring and standardization of education and training in hernia surgery.

MATERIALS AND METHODS

In 2011, the concept of a Hernia School was developed in Germany and has been gradually implemented ever since. That concept comprises the following series of interrelated, tiered course elements: Hernie kompakt (Hernia compact), Hernie konkret (Hernia concrete), and Hernie complex (Hernia complex). All three course elements make provision for structured clinical training based on guest visits to approved hernia centers. The Hernia compact basic course imparts knowledge of anatomy working with fresh cadavers. Hernia surgery procedures can also be conducted using unfixed specimens. Knowledge of abdominal wall ultrasound diagnostics is also imparted and hernia surgery procedures simulated on pelvic trainers. In all three course elements, lectures are delivered by experts across the entire field of hernia surgery using evidence-based practices from the literature.

RESULTS

To date, eight Hernie kompakt (Hernia compact) courses have been conducted, in each case with up to 55 participants, and with a total of 390 participants. On evaluating the course, over 95% of participants expressed the view that the Hernia compact course content improved hernia surgery training. Following that positive feedback, the more advanced Hernie konkret (Hernia concrete) and Hernie complex (Hernia complex) course elements were introduced in 2016.

CONCLUSION

The experiences gained to date since the introduction of a Hernia School-a standardized curriculum concept for continuing training in hernia surgery-has been evaluated by participants as an improvement on hitherto hernia surgery training.