Impact of Trainee Participation on Inguinal Hernia Repair Outcome: A Study Based on the Swedish Hernia Register

Specialists Versus Trainees: Long-Term Secondary Deformity After Unilateral Cleft Lip Repair

BACKGROUND

Unilateral cleft lip repair is a common procedure in plastic and reconstructive surgery to restore both function and aesthetics. The long-term outcomes of these surgeries can be influenced by various factors, including the experience and position of the surgeon performing the procedure. This study aims to investigate whether there is a significant difference in long-term secondary deformities based on whether the surgery was performed by a specialist or a trainee.

METHODS AND MATERIALS

This is a retrospective cross-sectional study among unilateral cleft lip patients based on their data records. The study aims to assess the long-term secondary deformity in relation to the position of the surgeon (specialist or trainee) in patients who underwent unilateral cleft lip repair surgery at the Reconstructive Sciences Unit at Hospital Universiti Sains Malaysia (HUSM).

RESULTS

Of the 50 patients, the majority (74%) were operated on by a specialist with more than five years of experience. Only 13 patients (26%) were operated on by trainees in the plastic and reconstructive surgery training program. Long-term secondary deformity had no significant relationship with the surgeon's position (chi-squared (χ2)(1) = 5.89, p = 0.08).

CONCLUSION

Long-term secondary deformities were less likely following unilateral cleft lip repair performed by a specialist or senior surgeon. However, the relationship between these secondary deformities and the surgeon's position (specialist or trainee) was statistically insignificant. Therefore, this study urges trainees to be more involved in simple cleft surgeries to enhance their surgical skills and achieve the best outcomes.

Influence of surgical volume on the mortality and morbidity of gastrointestinal perforation in children

PURPOSE

To clarify the influence of surgical volume on the mortality and morbidity of gastrointestinal perforation in children in Japan.

METHODS

We collected data on pediatric patients with gastrointestinal perforation between 2017 and 2019, from the National Clinical Database. The surgical volumes of various institutions were classified into three groups: low (average number of surgeries for gastrointestinal perforation/year < 1), medium (≥ 1, < 6), and high (≥ 6). The observed-to-expected (o/e) ratios of 30-day mortality and morbidity were calculated for each group using an existing risk model.

RESULTS

Among 1641 patients (median age, 0.0 years), the 30-day mortality and morbidity rates were 5.2% and 37.7%, respectively. The 30-day mortality rates in the low-, medium-, and high-volume institutions were 4.9%, 5.3%, and 5.1% (p = 0.94), and the 30-day morbidity rates in the three groups were 26.8%, 39.7%, and 37.7% (p < 0.01), respectively. The o/e ratios of 30-day mortality were 1.05 (95% confidence interval [CI] 0.83-1.26), 1.08 (95% CI 1.01-1.15), and 1.02 (95% CI 0.91-1.13), and those of 30-day morbidity were 1.72 (95% CI 0.93-2.51), 1.03 (95% CI 0.79-1.28), and 0.95 (95% CI 0.56-1.33), respectively.

CONCLUSION

Surgical volume does not have significant impact on the outcomes of pediatric gastrointestinal perforation in Japan.

Learning curve in open groin hernia surgery: nationwide register-based study

BACKGROUND

Current recommendations regarding the number of open groin hernia repairs that surgical trainees are required to perform during their residency are arbitrarily defined and vary between different curricula. This register-based study sought to investigate the learning curve of surgeons performing open anterior mesh repair for groin hernia by assessing hernia recurrence rates, surgical complications and operating times in relation to the number of procedures performed.

METHOD

Nationwide data on open anterior mesh repair for groin hernia performed by surgical residents were collected from the Swedish Hernia Register between 2005 and 2020. The data were analysed in a cohort undergoing procedures carried out by surgeons performing their first registered repair as resident general surgeons. Repairs by surgeons with fewer than 30 repairs were excluded.

RESULTS

A total of 38 845 repairs carried out by 663 surgeons were included. Operation time decreased with increasing number of performed procedures, mean (s.d.) operation time was 79 (26) min for the first 15 procedures and 60 (23) min after 241 procedures (P <0.001). A turning point where complication rates began to decrease was seen after 60 procedures. Complication rates were 3.6 per cent (396 of 10 978) for procedures 31-60 and 2.7 per cent (157 of 5 798) for procedures 61-120 (P = 0.002). There was no significant relationship between the number of procedures performed and the rate of operation on for recurrence (P = 0.894).

CONCLUSION

Sixty performed procedures during surgical residency is a reasonable target for achieving competency to perform open anterior mesh repair for groin hernia safely without supervision.

Risk of Reoperation for Recurrence After Elective Primary Groin and Ventral Hernia Repair by Supervised Residents

Importance

Surgical training involves letting residents operate under supervision. Since hernia repair is a common procedure worldwide, it is a frequent part of the surgical curriculum.

Objective

To assess the risk of reoperation for recurrence after elective primary groin and ventral hernia repair performed by supervised residents compared with that by specialists.

Design, Setting, and Participants

This nationwide register-based cohort study included data from January 2016 to September 2021. Patients were followed up until reoperation, emigration, death, or the end of the study period. The study used data from the Danish Inguinal and Ventral Hernia Databases linked with data from the Danish Patient Safety Authority's Online Register via surgeons' unique authorization ID. The cohort included patients aged 18 years or older who underwent primary elective hernia repairs performed by supervised residents or specialists for inguinal, femoral, epigastric, or umbilical hernias. Hernia repairs were divided into the following 4 groups: Lichtenstein groin, laparoscopic transabdominal preperitoneal (TAPP) groin, open ventral, and laparoscopic ventral.

Exposures

Hernia repairs performed by supervised residents vs specialists.

Main Outcomes and Measures

Reoperation for recurrence, analyzed separately for all 4 groups.

Results

A total of 868 specialists and residents who performed 31 683 primary groin and 7777 primary ventral hernia repairs were included in this study. The median age of patients who underwent hernia repair was 60 years (IQR, 48-70 years), and 33 424 patients (84.7%) were male. There was no significant difference in the adjusted risk of reoperation after Lichtenstein groin hernia repair (hazard ratio [HR], 1.26; 95% CI, 0.99-1.59), laparoscopic groin hernia repair (HR, 1.01; 95% CI, 0.73-1.40), open ventral hernia repair (HR, 0.89; 95% CI, 0.61-1.29), and laparoscopic ventral hernia repair (HR, 2.96; 95% CI, 0.99-8.84) performed by supervised residents compared with those by specialists. There was, however, a slightly increased unadjusted, cumulative reoperation rate after Lichtenstein repairs performed by supervised residents compared with those by specialists (4.8% vs 4.2%; P = .048).

Conclusions and Relevance

The findings of this study suggest that neither open nor laparoscopic repair of groin and ventral hernias performed by supervised residents appeared to be associated with a higher risk of reoperation for recurrence compared with the operations performed by specialists. This indicates that residents may safely perform elective hernia repair when supervised as part of their training curriculum.

Robot-assisted groin hernia repair is primarily performed by specialized surgeons: a scoping review

Surgical residents routinely participate in open and laparoscopic groin hernia repairs. The increasing popularity of robot-assisted groin hernia repair could lead to an educational loss for residents. We aimed to explore the involvement of surgical specialists and surgical residents, i.e., non-specialists, in robot-assisted groin hernia repair. The scoping review was reported according to PRISMA-ScR guideline. A protocol was uploaded at Open Science Framework, and a systematic search was conducted in four databases: PubMed, EMBASE, Cochrane CENTRAL, and Web of Science. Included studies had to report on robot-assisted groin hernia repairs. Data charting was conducted in duplicate. Of the 67 included studies, 85% of the studies described that the robot-assisted groin hernia repair was performed by a surgical specialist. The rest of the studies had no description of the primary operating surgeon. Only 13% of the included studies reported that a resident attended the robot-assisted groin hernia repair. Thus, robot-assisted groin hernia repair was mainly performed by surgical specialists, and robot-assisted groin hernia repair therefore seems to be underutilized to educate surgical residents.

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.

Development and validation of risk models for mortality and morbidity in 12 major pediatric surgical procedures: A study from the National Clinical Database-Pediatric of Japan

PURPOSE

To establish and validate risk models of mortality and morbidity associated with 12 major pediatric surgical procedures using the National Clinical Database-Pediatric (NCD-P) data.

METHODS

We used the NCD-P data for the development and validation datasets. By using multivariate logistic regression to analyze the development dataset, we created a prediction model for 30-day mortality and morbidity in 12 major pediatric surgical procedures, including tracheoplasty, pneumonectomy, fundoplication, total/subtotal excision of malignant tumor, and surgeries for Hirschsprung disease, anorectal malformation, biliary atresia, choledocal cyst, midgut volvulus, funnel chest, gastrointestinal perforation, and intestinal obstruction. We selected variables that were almost identical to those used in the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P). The primary outcomes were 30-day mortality and composite morbidity. We assessed the obtained models using the C-indices of the development and validation datasets.

RESULTS

Overall, 10 and 21 variables were identified for mortality and morbidity, respectively. C-indices of mortality were 0.940 and 0.924 in the development and validation datasets, respectively. C-indices of morbidity were 0.832 and 0.830 in the development and validation datasets, respectively.

CONCLUSIONS

Based on the NCD-P data, we developed satisfactory risk models for mortality and morbidity prediction in major pediatric surgeries.

LEVEL OF EVIDENCE

Level I (Prognosis Study).