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Kao CT, Kaplan E, Perera M, Toshniwal S. Does medical benefit schedule (MBS) accurately reflect operative challenges of laparoscopic versus open inguinal hernia repair (IHR)? ANZ J Surg 2024; 94:771. [PMID: 38529809 DOI: 10.1111/ans.18932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Chien-Tse Kao
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Elan Kaplan
- Department of Surgery, Holmesglen Private Hospital, Melbourne, Victoria, Australia
| | - Marlon Perera
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Surgery, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Sumeet Toshniwal
- Department of Surgery, Knox Private Hospital, Melbourne, Victoria, Australia
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Adams ST, Scott M, West C, Walsh CJ. Separating the components of an abdominal wall fellowship. Ann R Coll Surg Engl 2024; 106:2-8. [PMID: 36374299 PMCID: PMC10757876 DOI: 10.1308/rcsann.2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 01/02/2024] Open
Abstract
Complex abdominal wall reconstruction is an emerging subspecialty yet, despite the abundance of abdominal wall hernias requiring treatment and the increasing complexity of this type of surgery, there are few opportunities for surgeons to gain subspecialist training in this field. In this paper we discuss the need for focused training in complex abdominal wall reconstruction, outline some of the problems that may be hindering the availability of such opportunities and propose potential solutions to these issues.
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Affiliation(s)
- ST Adams
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
- Wirral University Teaching Hospitals (WUTH) NHS Foundation Trust, UK
| | - M Scott
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - C West
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - CJ Walsh
- Wirral University Teaching Hospitals (WUTH) NHS Foundation Trust, UK
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Brucchi F, Ferraina F, Masci E, Ferrara D, Bottero L, Faillace GG. Standardization and learning curve in laparoscopic hernia repair: experience of a high-volume center. BMC Surg 2023; 23:212. [PMID: 37507714 PMCID: PMC10385909 DOI: 10.1186/s12893-023-02119-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/22/2023] [Indexed: 07/30/2023] Open
Abstract
PURPOSE Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons. METHODS The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors' experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed. RESULTS The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia. CONCLUSIONS The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency.
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Affiliation(s)
- Francesco Brucchi
- Department of General Surgery, Sesto San Giovanni Hospital, Viale Matteotti, 83, Milan, MI, 20099, Italy.
- Department of General Surgery, Edoardo Bassini Hospital, Cinisello Balsamo, MI, Italy.
| | - Federica Ferraina
- Department of General Surgery, Sesto San Giovanni Hospital, Viale Matteotti, 83, Milan, MI, 20099, Italy
- Department of General Surgery, Edoardo Bassini Hospital, Cinisello Balsamo, MI, Italy
| | - Emilia Masci
- Department of General Surgery, Edoardo Bassini Hospital, Cinisello Balsamo, MI, Italy
| | - Davide Ferrara
- Department of General Surgery, Edoardo Bassini Hospital, Cinisello Balsamo, MI, Italy
| | - Luca Bottero
- Department of General Surgery, Edoardo Bassini Hospital, Cinisello Balsamo, MI, Italy
| | - Giuseppe G Faillace
- Department of General Surgery, Sesto San Giovanni Hospital, Viale Matteotti, 83, Milan, MI, 20099, Italy
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Fernandez-Alberti J, Mata L, Orrego F, Medina P, Bogetti D, Porto EA, Pirchi DE. Laparoscopic inguinal hernia repair: impact of surgical time in the learning curve. Surg Endosc 2022; 37:2826-2832. [PMID: 36477644 DOI: 10.1007/s00464-022-09807-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE One of the procedures that has become very popular thanks to the advantages of minimally invasive approach is the laparoscopic treatment of inguinocrural hernias. As a disadvantage, it would imply a longer learning curve when compared to the conventional approach. There is no consensus about the number of procedures required to dominate this surgical technique, since according to bibliography it ranges from 20 to 240. METHODS We analyzed and compared the progress of 18 third year surgical residents while they were introducing into laparoscopic transabdominal preperitoneal inguinal hernioplasties between June 2013 and May 2018. RESULTS Between June 2013 and May 2018, 1282 laparoscopic inguinal hernioplasties were performed (71 procedures per resident). Mean surgical time was for unilateral: 62.13 min (SD ± 15.54; range 30-105 min) for the first third (Q1) vs 54.61 min (SD ± 15.38; range 30-100 min) for the last third (Q3): p < 0.0001. For bilateral were: 92.59 min (SD ± 21.89; range 50-160 min) for Q1 vs 84.48 min (SD ± 20.52; range 30-130 min) for Q3: p < 0.05. Accepting an alpha error of 5% and considering an association power of 80%, there would be needed 61 cases per surgeon to achieve a significant reduction in surgical time. CONCLUSION In a center with high-volume in TAPP and under a supervised training program, it is feasible to achieve a reduction in surgical time. Randomized studies with a larger number of cases are necessary to confirm this finding and draw more robust and objective conclusions.
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Affiliation(s)
| | - Lautaro Mata
- General Surgery Department, Hospital Británico de Buenos Aires, Perdriel 74, 1280, CABA, Argentina
| | - Facundo Orrego
- General Surgery Department, Hospital Británico de Buenos Aires, Perdriel 74, 1280, CABA, Argentina
| | - Pablo Medina
- Abdominal Wall Surgery Department, Hospital Británico de Buenos Aires, Perdriel 74, 1280, CABA, Argentina
| | - Diego Bogetti
- General Surgery Department, Hospital Británico de Buenos Aires, Perdriel 74, 1280, CABA, Argentina
| | - Eduardo Agustin Porto
- Abdominal Wall Surgery Department, Hospital Británico de Buenos Aires, Perdriel 74, 1280, CABA, Argentina
| | - Daniel Enrique Pirchi
- Director of General Surgery Department, Hospital Británico de Buenos Aires, Perdriel 74, 1280, CABA, Argentina
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Sivakumar J, Chen Q, Hii MW, Cullinan M, Choi J, Steven M, Crosthwaite G. Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression. Surg Endosc 2022; 37:2453-2475. [PMID: 36416945 DOI: 10.1007/s00464-022-09760-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 11/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Laparoscopic inguinal hernia repair has a long learning curve. It can be a technically challenging procedure and initially presents an unfamiliar view of inguinal anatomy. The aim of this review was to evaluate published literature relating to the learning curve of laparoscopic inguinal hernia repair and identify the number of cases required for proficiency. The secondary aim was to compare outcomes between surgeons before and after this learning curve threshold had been attained. METHODS A systematic literature search was conducted in databases of PubMed, Medline, Embase, Web of Science, and Cochrane Library, to identify studies that evaluated the learning curve of laparoscopic inguinal hernia repair. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase of the curve. RESULTS Twenty-two studies were included in this review, with 19 studies included in the meta-regression analysis, and 11 studies included in the meta-analysis. Mixed-effects Poisson regression demonstrated that there was a non-linear trend in the number of cases required to achieve surgical proficiency, with a 2.7% year-on-year decrease. The predicted number of cases to achieve surgical proficiency in 2020 was 32.5 (p < 0.01). The meta-analysis determined that surgeons in their learning phase may experience a higher rate of conversions to open (OR 4.43, 95% CI 1.65, 11.88), postoperative complications (OR 1.61, 95% CI 1.07, 2.42), and recurrences (OR 1.32, 95% CI 0.40, 4.30). CONCLUSION Laparoscopic inguinal hernia repair has a well-defined learning curve. While learning surgeons demonstrated reasonable outcomes, supervision during this period may be appropriate given the increased risk of conversion to open surgery. These data may benefit learning surgeons in the skill development of minimally invasive inguinal hernia repairs.
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Affiliation(s)
- Jonathan Sivakumar
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia.
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia.
- Department of Surgery, The University of Melbourne, Melbourne, Australia.
| | - Qianyu Chen
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Michael W Hii
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Mark Cullinan
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Surgery, Monash University, Clayton, VIC, Australia
| | - Julian Choi
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Upper Gastrointestinal and Hepatobiliary Surgery, Western Health, Melbourne, Australia
| | - Mark Steven
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
| | - Gary Crosthwaite
- Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Australia
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Shah MY, Raut P, Wilkinson T, Agrawal V. Surgical outcomes of laparoscopic total extraperitoneal (TEP) inguinal hernia repair compared with Lichtenstein tension-free open mesh inguinal hernia repair: A prospective randomized study. Medicine (Baltimore) 2022; 101:e29746. [PMID: 35777031 PMCID: PMC9239617 DOI: 10.1097/md.0000000000029746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Inguinal hernia repair is one of the most frequently performed surgery. The ideal procedure for inguinal hernia repair remains controversial. Open Lichtenstein tension-free mesh repair (LMR) is one of the most preferred open techniques with satisfactory outcomes. Laparoscopic approach in inguinal hernia surgery remains controversial, especially in comparison with open procedures. In this study, we have reported a comparison of laparoscopic total extraperitoneal (TEP) inguinal hernia repair with LMR. Postoperative pain, operative time, complications like seroma, wound infection, chronic groin pain, and recurrence rate were parameters to evaluate the outcome. One hundred seventy-four patients were included in the study by consecutive randomized prospective sampling. The patients were divided into 2 groups: group A, laparoscopic TEP inguinal hernia repair, and group B, LMR. The procedures were performed by experienced surgeons. The primary outcomes were evaluated based on postoperative pain and recurrence rate. Secondary outcomes considered for evaluation were operative time, complications like seroma, infection, and chronic groin pain. Severe pain was reported in group A (7.9%) compared to group B (15.1%), which was statistically significant (P < .001). Moderate pain was reported more in group B (70.9%) compared to group A (29.5%) (P < .001). The mean operative time in group A was 84.6 ± 32.2, which was significantly higher than that in group B, 59.2 ± 14.8. There was no major complication in both groups. The chronic pain postoperatively was significantly in higher number of patients in group B vs group A (22.09% vs 3.4%). The postoperative hospital stay period was significantly lesser for group A vs for group B (2.68 ± 1.52 vs 3.86 ± 6.16). Time duration taken to resume normal activities was significantly lower in group A (13.6 ± 6.8) vs (19.8 ± 4.6) in group B (P < .001). Although there is definite evidence of longer operative time and learning curve, laparoscopic TEP has added advantages like less postoperative pain, early resumption of normal activities, less chronic groin pain, and comparable recurrence rate compared to open Lichtenstein repair. Laparoscopic TEP can be performed with acceptable outcomes and less postoperative complications if performed by experienced hands.
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Affiliation(s)
- Mohammed Yunus Shah
- Department of Minimal Access, Bariatric and General Surgery, Al Ahli Hospital, Qatar University, Doha, Qatar
- *Correspondence: Mohammed Yunus Shah, Department of Minimal Access, Bariatric and General Surgery, Al Ahli Hospital, Qatar University, P.O Box 6401, Doha, Qatar (e-mail: )
| | - Pratik Raut
- Maharashtra University of Health Sciences, Maharashtra, India
| | - T.R.V. Wilkinson
- Department of Surgery, NKP Salve Medical College and Research Centre, Nagpur, Maharashtra, India
| | - Vijay Agrawal
- Maharashtra University of Health Sciences, Maharashtra, India
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