Team Training (Training at Own Facility) versus Individual Surgeon's Training (Training at Trainer's Facility) When Implementing a New Surgical Technique: Example from the ONSTEP Inguinal Hernia Repair

Recurrence mechanisms after inguinal hernia repair by the Onstep technique: a case series

PURPOSE

Inguinal hernia repairs should have few complications and a short learning curve. A new operation called Onstep has promising results, but still some recurrences. The aim of the study was to find reasons for recurrence, by studying the re-operations.

METHODS

The study is a case series, where 565 patients operated with Onstep at six hospitals between December 2011 and April 2015 were identified. If a recurrence had occurred, the description of the re-operation was studied and compared to the primary Onstep operation.

RESULTS

We found 26 inguinal hernia recurrences, giving a recurrence rate of 4.6 %. The reasons for recurrence were a cranial displacement of the mesh in five patients, a caudal displacement in three patients, a folded mesh in one patient, and broken sutures in the mesh laterally in six patients. We found indications of a learning curve, since 70 % of the recurrences had their primary operation among the first half of the total Onstep procedures. Another finding was that 30 patients had complaints from the ring in the mesh, and most of these patients were slender. Fifteen patients have had the ring removed, and for six patients with a follow-up, the complaints have been reduced or disappeared.

CONCLUSIONS

The main reasons for recurrence may be broken sutures in the mesh laterally or a suboptimal size of the opening in fascia transversalis medially, enabling the mesh to displace. Furthermore, the results suggest a learning curve. These findings may guide further improvement in the Onstep method for inguinal hernia repair.

Difficulties and Problematic Steps in Teaching the Onstep Technique for Inguinal Hernia Repair, Results from a Focus Group Interview

Background. When a new surgical technique is brought into a department, it is often experienced surgeons that learn it first and then pass it on to younger surgeons in training. This study seeks to clarify the problems and positive experiences when teaching and training surgeons in the Onstep technique for inguinal hernia repair, seen from the instructor's point of view. Methods. We designed a qualitative study using a focus group to allow participants to elaborate freely and facilitate a discussion. Participants were surgeons with extensive experience in performing the Onstep technique from Germany, UK, France, Belgium, Italy, Greece, and Sweden. Results. Four main themes were found, with one theme covering three subthemes: instruction of others (experience, patient selection, and tailored teaching), comfort, concerns/fear, and anatomy. Conclusion. Surgeons receiving a one-day training course should preferably have experience with other types of hernia repairs. If trainees are inexperienced, the training setup should be a traditional step-by-step programme. A training setup should consist of an explanation of the technique with emphasis on anatomy and difficult parts of the procedure and then a training day should follow. Surgeons teaching surgery can use these findings to improve their everyday practice.