Learning curve in open inguinal hernia repair: a quality improvement multicentre study about Lichtenstein technique

Trends in minimally invasive and open inguinal hernia repair: an analysis of ACGME general surgery case logs

BACKGROUND

Groin hernia repair is one of the most commonly performed surgical procedures and is often performed by surgical interns and junior residents. While traditionally performed open, minimally invasive (MIS) groin hernia repair has become an increasingly popular approach. The purpose of this study was to determine the trends in MIS and open inguinal and femoral hernia repair in general surgery residency training over the past two decades.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residents from 1999 through 2022 were reviewed. We collected means and standard deviations of open and MIS inguinal and femoral hernia repairs. Linear regression and ANOVA were used to identify trends in the average annual number of open and MIS hernia repairs logged by residents. Cases were distinguished between level of resident trainees: surgeon-chief (SC) and surgeon-junior (SJ).

RESULTS

From July 1999 to June 2022, the average annual MIS inguinal and femoral hernia repairs logged by general surgery residents significantly increased, from 7.6 to 47.9 cases (p < 0.001), and the average annual open inguinal and femoral hernia repairs logged by general surgery residents significantly decreased, from 51.9 to 39.7 cases (p < 0.001). SJ resident results were consistent with this overall trend. For SC residents, the volume of both MIS and open hernia repairs significantly increased (p < 0.001).

CONCLUSIONS

ACGME case log data indicates a trend of general surgery residents logging overall fewer numbers of open inguinal and femoral hernia repairs, and a larger proportion of open repairs by chief residents. This trend warrants attention and further study as it may represent a skill or knowledge gap with significant impact of surgical training.

Meta-analysis of the effectiveness and safety of robotic-assisted versus laparoscopic transabdominal preperitoneal repair for inguinal hernia

BACKGROUND

Inguinal hernia is a common global disease. This study aims to investigate the effectiveness and safety of robot-assisted transabdominal preperitoneal repair (RTAPP) and laparoscopic transabdominal preperitoneal repair (LTAPP) for inguinal hernia.

METHODS

We conducted a thorough search in Cochrane Library, Embase, and PubMed for relevant clinical studies. After applying inclusion and exclusion criteria, the quality of selected studies was assessed using the Jadad scale for randomized controlled studies and the Newcastle-Ottawa scale for observational studies. Meta-analysis was performed using RevMan 5.3 software.

RESULTS

A total of ten studies were included, comprising two randomized controlled studies and eight non-randomized controlled studies. Meta-analysis results revealed no statistically significant differences between the RTAPP group and the LTAPP group regarding hospital stay [MD = 0.21 days, 95% CI (-0.09, 0.51), P = 0.17], incidence of seroma [OR = 0.85, 95% CI(0.45, 1.59), P = 0.61], overall complication rate [OR = 1.22, 95% CI(0.68, 2.18), P = 0.51], readmission rate [OR = 1.31, 95% CI(0.23, 7.47), P = 0.76], and recurrence rate [OR = 0.82, 95% CI(0.22, 3.07), P = 0.77]. However, the RTAPP group had longer operation time compared to the LTAPP group [MD = 14.02 minutes, 95% CI (6.65, 21.39), P = 0.0002], and the cost of the RTAPP procedure was higher than that of the LTAPP procedure [MD = $4.17 thousand, 95% CI (2.59, 5.76), P<0.00001].

CONCLUSION

RTAPP for inguinal hernia is a safe and feasible approach, however, it is associated with increased operation time and treatment costs.

Separating the components of an abdominal wall fellowship

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.

Assessing knowledge and confidence of surgical residents in inguinal hernia repair using a low-cost synthetic model

PURPOSE

Open repair of groin hernia is an essential skill for the general surgeon. This study aimed to develop a low-cost hernia model based on a validated high-fidelity model and assess its effectiveness in teaching inguinal hernia repair to surgical trainees from many institutions throughout Africa.

METHODS

Using inexpensive, locally available materials, a low-cost hernia model was created. Six models were constructed, and a workshop was conducted for surgical residents. Pre- and post-workshop surveys were administered to assess knowledge, confidence, and understanding. Statistical analyses were performed using paired t tests and the Wilcoxon signed-rank test.

RESULTS

The low-cost hernia model consisted of various readily available materials and cost an average of $5.07. Sixty-eight trainees participated in the workshop, and 59 completed the post-workshop survey. Participants reported a significant increase in confidence for both mesh and non-mesh repairs and an improved understanding of hernia anatomy after the workshop. Trainees scored an average of 5.6 (SD 1.9) out of 10 questions on the pre-workshop quiz and 7.9 (SD 1.4) out of 10 on the post-workshop quiz (p < 0.001), indicating improved knowledge. All trainees supported the use of the model for education.

CONCLUSION

The low-cost hernia model demonstrated its effectiveness in enhancing trainees' understanding of hernia anatomy and increasing their confidence in hernia repair. Integrating low-cost hernia models into training programs can help improve trainees' knowledge and confidence in a safe and affordable environment.

Risk factors for reoperation following inguinal hernia repair: results from a cohort of patients from an integrated healthcare system

PURPOSE

Inguinal hernia repair is one of the most common operations performed globally. Identification of risk factors that contribute to hernia recurrence following an index inguinal hernia repair, especially those that are modifiable, is of paramount importance. Therefore, we sought to investigate risk factors for reoperation following index inguinal hernia repair.

METHODS

125,133 patients aged ≥ 18 years who underwent their first inguinal hernia repair with mesh within a large US integrated healthcare system were identified for a cohort study (2010-2020). Laparoscopic, robotic, and open procedures were included. The system's integrated electronic health record was used to obtain data on demographics, patient characteristics, surgical characteristics, and reoperations. The association of these characteristics with ipsilateral reoperation during follow-up was modeled using Cox proportional-hazards regression. Risk factors were selected into the final model by stepwise regression with Akaike Information Criteria, which quantifies the amount of information lost if a factor is left out of the model. Factors associated with reoperation with p < 0.05 were considered statistically significant.

RESULTS

The cumulative incidence of reoperation at 5-year follow-up was 2.4% (95% CI 2.3-2.5). Increasing age, female gender, increasing body mass index, White race, chronic pulmonary disease, diabetes, drug abuse, peripheral vascular disease, and bilateral procedures all associated with a higher risk for reoperation during follow-up.

CONCLUSION

This study identifies several risk factors associated with reoperation following inguinal hernia repair. These risk factors may serve as targets for optimization protocols prior to elective inguinal hernia repair, with the goal of reducing reoperation risk.

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.

Inguinal hernia surgery learning curves by associate clinicians

BACKGROUND

Open inguinal hernia repair is the most commonly performed procedure in general surgery in sub-Saharan Africa, but data on its learning curve are lacking. This study evaluated the learning curve characteristics to improve surgical training and enable scaling up hernia surgery in low- and middle-income countries.

METHODS

Logbook data of associate clinicians enrolled in a surgical training program in Sierra Leone were collected and their first 55 hernia surgeries following the Bassini technique (herniorrhaphies) were analyzed in cohorts of five cases. Studied variables were gradient of decline of operating time, variation in operating time, and length of stay (LOS). Eleven subsequent cohorts of each five herniorrhaphies were investigated.

RESULTS

Seventy-five trainees enrolled in the training program between 2011 and 2020 were eligible for inclusion. Thirty-one (41.3%) performed the minimum of 55 herniorrhaphies, and had also complete personal logbook data. Mean operating times dropped from 79.6 (95% CI 75.3-84.0) to 48.6 (95% CI 44.3-52.9) minutes between the first and last cohort, while standard deviation in operating time nearly halved to 15.4 (95% CI 11.7-20.0) minutes, and LOS was shortened by 3 days (8.5 days, 95%CI 6.1-10.8 vs. 5.4 days, 95% 3.1-7.6). Operating times flattened after 31-35 cases which corresponded with 1.5 years of training.

CONCLUSIONS

The learning curve of inguinal hernia surgery for associate clinicians flattens after 31-35 procedures. Training programs can be tailored based on this finding. The recorded learning curve may serve as a baseline for future training techniques.

Robotic versus laparoscopic transabdominal preperitoneal (TAPP) approaches to bilateral hernia repair: a multicenter retrospective study using propensity score matching analysis

BACKGROUND

Since the introduction of minimally invasive surgery, new techniques like transabdominal preperitoneal (TAPP) repair have progressively gained acceptance for the treatment of groin hernia. Laparoscopic TAPP (LTAPP) is recommended for bilateral repairs. Likewise, the introduction of robotic platforms has promised additional surgical benefits for robotic TAPP (RTAPP), which are yet to be confirmed. This study compared multicenter data obtained from patients undergoing bilateral inguinal hernia repair with RTAPP, performed during the preliminary learning curve period, versus conventional LTAPP.

MATERIALS AND METHODS

All consecutive bilateral inguinal hernia patients from four Italian centers between June 2015 and July 2020 were selected. A propensity score model was used to compare patients treated with LTAPP versus RTAPP, considering sex, age, body mass index, current smoking status, overall comorbidity, hernia classification (primary or recurrent), and associated procedures as covariates. After matching, intraoperative details and postoperative outcomes were evaluated.

RESULTS

In total, 275 LTAPP and 40 RTAPP were performed. After matching, 80 and 40 patients were allocated to the LTAPP and RTAPP cohorts, respectively. No intraoperative complications or conversion to open surgery occurred. However, a longer operative time was recorded in the RTAPP group (79 ± 21 versus 98 ± 29 min; p < 0.001). Postoperative visual analog scale (VAS) pain scores (p = 0.13) did not differ and complication rates were similar. There were no clinical recurrences in either group, with mean follow-up periods of 52 ± 14 (LTAPP) and 35 ± 8 (RTAPP) months. A statistical difference in length of hospital stay was found between the groups (1.05 ± 0.22 vs 1.50 ± 0.74 days; p < 0.001).

CONCLUSION

In this patient population, outcomes for bilateral inguinal hernia repair appear comparable for RTAPP and LTAPP, except for a shorter recovery after laparoscopic surgery. A longer operative time for robotic surgery could be attributable to the learning curve period of each center.

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward.

Minimally Invasive Repair of Recurrent Inguinal Hernia: Multi-Institutional Retrospective Comparison of Robotic Versus Laparoscopic Surgery

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression

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.

Regional block anesthesia for adult patients with inguinal hernia repair: A systematic review

BACKGROUND

Inguinal hernia repair (IHR) is a common surgical technique performed under regional block anesthesia (RBA). Although previous clinical trials have explored the effectiveness and safety of RBA for IHR, no systematic review has investigated its effectiveness and safety in adult patients with IHR.

METHODS

This systematic review searched electronic databases (PubMed, Embase, Cochrane Library, CNKI, Wangfang, and VIP) from their inception to July 1, 2022. We included all potential randomized controlled trials that focused on the effects and safety of RBA in adult patients with IHR. Outcomes included operative time, total rescue analgesics, numerical rating scale at 24 hours, occurrence rate of nausea and vomiting, and occurrence rate of urinary retention (ORUCR).

RESULTS

Five randomized controlled trials, involving 347 patients with IHR, were included in this study. Meta-analysis results showed that no significant differences were identified on operative time (MD = -0.20; fixed 95% confidence interval [CI], -3.87, 3.47; P = .92; I² = 0%), total rescue analgesics (MD = -8.90; fixed 95% CI, -20.36, 2.56; P = .13; I² = 28%), and occurrence rate of nausea and vomiting (MD = 0.39; fixed 95% CI, 0.13, 1.16; P = .09; I² = 0%) between 2 types of anesthesias. However, significant differences were detected in the numerical rating scale at 24 hours (MD = -1.53; random 95% CI, -2.35, -0.71; P < .001; I² = 75%) and ORUCR (MD = 0.20; fixed 95% CI, 0.05, 0.80; P = .02; I² = 0%) between the 2 management groups.

CONCLUSION

The results of this study demonstrated that IHR patients with RBA benefit more from post-surgery pain relief at 24h and a decrease in the ORUCR than those with CSA.

Inguinal hernia in southern Brazil - challenges in follow-up and recurrence rates

INTRODUCTION

recurrence rates for primary hernia repair range from 0.5 to 15 percent depending upon the hernia site, type of repair, and clinical circumstances. Many risk factors are known and they must be considered before the procedure. In developing countries, follow up and maintenance of databases are critical to understand the real numbers.

METHODS

a retrospective cohort study analyzed adult patients who have undergone inguinal hernia repair at Hospital de Clínicas de Porto Alegre, a tertiary care government public hospital, between 2013 and 2015. Medical records, telephone, and letter contact have been reviewed in order to complete the minimum period of 5 years of follow-up. The analyzed data focused on the surgeon's experience and the recurrence rate in 5 years of follow-up.

RESULTS

a total of 1094 medical records were selected and a complete five years follow-up were possible in 454 patients - 538 inguinal hernia repairs due to bilateral approach in 84 patients. These 454 patients answered, in a validated questionnaire about symptoms of recurrence. The total recurrence rate was 9.29%. For the patients who had Nyhus IV, recurrence rate was 24.1% against 9.9% after primary hernia repair, with a 2.4 higher risk. There was no difference in recurrence between surgeons and training surgeons.

CONCLUSION

our data reveal an acceptable recurrence rate in a tertiary care hospital with residents, and to our knowledge is the first Brazilian report with long term follow up. An increased re-recurrent hernia was found when compared with primary hernia repair.

Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment

OBJECTIVE

We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending.

DESIGN

We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications.

SETTING

Tertiary care center, single institution.

PARTICIPANTS

Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period.

RESULTS

Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09).

CONCLUSIONS

Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.

Defining operative experience targets in surgical training: A systematic review

BACKGROUND

The surgical learning curve is an observable and measurable phenomenon. Operative experience targets are well established as a proxy measure for operative competence in surgical training across jurisdictions. The aim of this study was to critique the available evidence regarding the relationship between operative experience in surgical training and trainee competence.

METHODS

A systematic review of the PubMed, Embase, Web of Science, and Cochrane library databases was conducted in accordance with the Preferred Items for Systematic Reviews and Meta-Analyses guidelines. Articles were sought that defined the relationship between procedural volume in surgical training and trainee competence, proficiency, or mastery. The educational impact of included studies was evaluated using a modified Kirkpatrick model.

RESULTS

Of 3,672 records identified on database searching, 30 papers were ultimately included. Fourteen studies defined operative experience thresholds using operative time as a surrogate measure of competence, whereas another 8 used trainer assessments of operative performance (Kirkpatrick level 3). A further 5 studies were able to determine the relationship between trainee case volumes and subsequent patient outcomes (Kirkpatrick level 4b).

CONCLUSION

Many studies have recorded competent trainee performance in key index procedures after reaching experience threshold numbers in excess of currently mandated targets across jurisdictions. The evidence relating current operative experience targets to patient outcomes across a range of surgical subspecialties of surgical subspecialties is lacking. This review supports a move toward criterion-based referencing of operative performance targets in surgical training.

Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis

INTRODUCTION

Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve.

METHODS

Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve.

RESULTS

Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications.

CONCLUSIONS

This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.

Assessing Operative Skill in the Competency-based Education Era: Lessons From the UK and Ireland

INTRODUCTION

Decisions regarding the operative competence of surgical residents in the United Kingdom and Ireland are informed by operative workplace-based assessments (WBAs) and operative number targets for index procedures. This review seeks to outline the validity evidence of these assessment methods.

METHODS

A review of the MEDLINE (Pubmed), EMBASE and Cochrane Library databases was undertaken in accordance with the Joanna Briggs Institute Protocol for Scoping Reviews (2020). Articles were included if they provided evidence of the validity of procedure-based assessments, direct observation of procedural skills, or indicative operative number targets. The educational impact of each article was evaluated using a modified Kirkpatrick model.

RESULTS

Twenty-eight articles outlining validity evidence of WBAs and operative number targets were synthesised by narrative review. Five studies documented users' views on current assessment methods (Kirkpatrick level 1). Two articles recorded changes in attitudes towards current operative assessments (level 2a). Ten studies documented the ability of current assessments to record improvements in operative competence (level 2b). Ten studies measured a change in behaviour as a result of the introduction of these assessments (level 3). One article studied the ability of operative assessments to predict clinical outcomes (level 4b).

CONCLUSIONS

Operative WBAs are reliable. Scores achieved correlate with both time spent in training and recorded operative experience. Trainers and residents have concerns regarding the subjectivity of these assessments and the opportunistic nature in which they are used. Operative number targets are not criterion-referenced, lack validity evidence, and may be set too low to ensure operative competence.

The Effect of Intraoperative Transversus Abdominis Plane Blocking on Postoperative Pain After Laparoscopic Transabdominal Pre-peritoneal (TAPP) Groin Hernia Repair

Background

Managing postoperative pain even after laparoscopic groin hernia repair still remains an interesting challenge for clinicians especially for patients of high risk. Plenty of operative techniques and analgesic methods have been proposed in order to minimize postoperative pain after laparoscopic groin hernia repair. The aim of the present study is to compare transverse abdominis plane (TAP)-block with local analgesic infiltration at trocar entry sites in the terms of reducing postoperative pain.

Methods

Patients that underwent laparoscopic trans-abdominal pre-peritoneal (TAPP) groin hernia repair in a high-volume university hospital were included. Patients were divided in two groups depending on the analgesic method used. Pain was assessed using Visual Numerical Scale (VNS) score.

Results

Thirty patients were included. Intraoperative TAP-block seemed to be superior in terms of decreasing pain at the hernia area and at the trocar insertion site (p &lt; 0.05) compared to local analgesic infiltration at the trocar insertion site at 6, 12 and 24 h after surgery (p &lt; 0.05). In addition, pain reduction was more effective in rest rather than in motion for both analgesic methods.

Conclusion

Intraoperative TAP-block under direct vision seems to be an effective, fast and easy technique in order to reduce postoperative pain after laparoscopic groin hernia repair, but more studies are required to validate these results in a prospective and randomized context.

Incisional hernia repair after kidney transplantation in a tertiary high-volume center: outcomes from a 10-year retrospective cohort study

BACKGROUND AND AIM

Incisional hernia (IH) after Kidney Transplantation (KT) is a challenging complication due to both technical reasons and patients' complexity. Data regarding outcomes of hernia repair in KT recipients are uncertain, since the biggest part of previous papers focused on risk factors for incisional hernia occurrence and not on its outcomes. Aim of the study was to focus on risk factors for incisional hernia recurrence after surgical repair in KT recipients.

METHODS

Data regarding all consecutive patients undergoing kidney transplantations from January 2011 until September 2020 in Montpellier University Hospital were retrospectively collected from a single institutional database.

RESULTS

After a median follow-up of 48 months (IQR_25-75 31-59), data from 1546 consecutive KT were collected. 83 patients underwent 99 incisional hernia surgeries after KT, with 14 patients that had one recurrence (14.4%) and 2 patients that experienced two recurrences (2.4%). Total recurrence rate was 16.8%. At univariate analysis, the only factor associated with an incisional hernia recurrence was having undergone to at least one previous abdominal surgery other than KT (p value 0.002). Overall morbidity was 15% (n = 15), with most of complications classified as mild (59%). No mortality related to incisional hernia repair occurred.

CONCLUSION

IHs after KT represent an important condition. Its surgical management is challenging due to its anatomical complexity and patient's status. This is the largest sample size in the literature of patients treated for IH after KT and it shows that a previous surgery other than the KT is a risk factor for hernia recurrence after surgical repair, without regarding surgical technique or other comorbidity and therapeutical factors.

Learning Curve for Metastatic Liver Tumor Open Resection in Patients with Primary Colorectal Cancer: Use of the Cumulative Sum Method

Background: Liver resections have become the first-line treatment for primary and metastatic tumors and, therefore, are considered a core aspect of surgical training. This study aims to evaluate the learning curve of the extent and safety of liver resection procedures for patients with metastatic colorectal cancer. Methods: This single tertiary center retrospective analysis includes 158 consecutive cases of small liver resection (SLR) (n = 107) and major liver resection (MLR) (n = 58) procedures. A cumulative sum control chart (CUSUM) method was used to investigate the learning curve. Results: The operative time, total blood loss level, and incidence of adverse effects showed a learning curve. For SLRs, the CUSUM curve for operative time and blood loss level peaked at the 19th and 17th case, respectively, while for MLRs, these curves peaked at the 28th and 24th case, respectively. The CUSUM curve for minor adverse effects (MAEs) and severe adverse effects (SAEs) showed a downward slope after the 16th and 68th procedures in the SLRs group and after the 29th and 39th procedures in the MLRs cohort; however, it remained within the acceptable range throughout the entire study. Conclusion: SLR procedures were performed faster with less intraoperative blood loss and shorter postoperative stays than MLRs, and a higher number of completed procedures was required to gain stabilization and repeatability in the operating time and intraoperative blood loss level. In MLR procedures, the reduction of SAEs was accomplished significantly later than the stabilization of the operative time and intraoperative blood loss level.

Hérnia inguinal no Sul do Brasil - desafios no seguimento e taxas de recorrência

RESUMO Introdução: a recorrência da hérnia inguinal após hernioplastia varia de 0,5 a 15 por cento, dependendo do local da hérnia, tipo de reparo e circunstâncias clínicas. Muitos fatores de risco são conhecidos e devem ser considerados antes do procedimento. Acompanhamento e adequado bancos de dados são fundamentais para entender a incidência de recidiva. Métodos: estudo de coorte retrospectivo analisou hernioplastias inguinais realizados no Hospital de Clínicas de Porto Alegre entre 2013 e 2015. Para concluir 5 anos de seguimento, analisamos o prontuário e fizemos contato telefônico e por correio. Resultados: o total de 1094 registros médicos foram selecionados e um seguimento de pelo menos 5 anos foi possível em 454 pacientes - 538 reparos de hérnia inguinal devido à abordagem bilateral em 84 pacientes. Os pacientes responderam um questionário validado sobre sintomas de recorrência. A taxa total de recorrência foi de 9,29%. No grupo masculino, a recorrência foi de 10% contra 4% no grupo feminino. Para os pacientes com hérnia Nyhus IV, a recidiva foi de 24% contra 8% após o reparo da hérnia primária, com um risco de 2,8 maior. Não houve diferença na recorrência entre cirurgiões experientes e em treinamento. Conclusão: nossos dados revelam uma taxa de recorrência aceitável em um hospital de ensino, e para o nosso conhecimento é o primeiro artigo com acompanhamento de longo prazo no sul do Brasil. A re-recidiva da hérnia foi maior quando comparada com o reparo da hérnia primária.

Inguinal Hernia Mesh Repair: The Factors to Consider When Deciding Between Open Versus Laparoscopic Repair

Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide. An inguinal hernia occurs due to a defect in the abdominal wall, which allows the abdominal contents to pass through it. Although the placement of mesh over the defect is the gold standard to close the defect, there are various approaches to achieving it, out of which two of the most widely accepted techniques are laparoscopic inguinal hernia repair (LIHR) and open inguinal hernia repair (OIHR). However, the approach of choice widely fluctuates with regards to various factors such as patient history, type of hernias, and surgeons' preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient in deciding the technique to be undertaken. This article has reviewed many studies and compared the two techniques in terms of chronic pain, the time required to return to activity, rate of recurrence, and cost-effectiveness.

Transversus abdominis release (TAR) for ventral hernia repair: open or robotic? Short-term outcomes from a systematic review with meta-analysis

PURPOSE

To compare early postoperative outcomes after transversus abdominis release (TAR) for ventral hernia repair with open (oTAR) and robotic (rTAR) approach.

METHODS

A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Web of Science databases was conducted to identify comparative studies until October 2020. A meta-analysis of postoperative short-term outcomes was performed including complications rate, operative time, length of stay, surgical site infection (SSI), surgical site occurrence (SSO), SSO requiring intervention (SSOPI), systemic complications, readmission, and reoperation rates as measure outcomes.

RESULTS

Six retrospective studies were included in the analysis with a total of 831 patients who underwent rTAR (n = 237) and oTAR (n = 594). Robotic TAR was associated with lower risk of complications rate (9.3 vs 20.7%, OR 0.358, 95% CI 0.218-0.589, p < 0.001), lower risk of developing SSO (5.3 vs 11.5%, OR 0.669, 95% CI 0.307-1.458, p = 0.02), lower risk of developing systemic complications (6.3 vs 26.5%, OR 0.208, 95% CI 0.100-0.433, p < 0.001), shorter hospital stay (SMD - 4.409, 95% CI - 6.000 to - 2.818, p < 0.001) but longer operative time (SMD 53.115, 95% CI 30.236-75.993, p < 0.01) compared with oTAR. There was no statistically significant difference in terms of SSI, SSOPI, readmission, and reoperation rates.

CONCLUSION

Robotic TAR improves recovery by adding the benefits of minimally invasive procedures when compared to open surgery. Although postoperative complications appear to decrease with a robotic approach, further studies are needed to support the real long-term and cost-effective advantages.

Short-term comparative study of three-dimensional and two-dimensional laparoscopic surgery for total extraperitoneal primary inguinal hernia repair

Purpose

The aim of this study was to compare the short-term outcomes of two-dimensional (2D) and three-dimensional (3D) laparoscopic surgery for total extraperitoneal (TEP) primary inguinal hernia repair.

Methods

This was a single-center, retrospective, observational database study of 38 patients who underwent laparoscopic TEP inguinal hernia repair from March 1, 2019 to August 30, 2019 at Kyung Hee University Hospital at Gangdong in Seoul, Korea.

Results

There was no significant difference in sex ratio, age, or body mass index between the two groups. The 2D group had two patients with direct hernia and 18 patients with indirect hernia. The 3D group had five patients with direct hernia, 11 patients with indirect hernia, and two patients with femoral hernia. The mean operation time was 38.2 minutes in the 2D group compared with 37.2 minutes in the 3D group. There was no severe intraoperative bleeding in either group. During the operation, peritoneal tearing occurred in 12 out of 20 patients in the 2D group compared with five out of 18 patients in the 3D group (p = 0.02). The average length of hospital stay was 1.3 days in both groups. The numeric rating scale score was 3.3 and 3 in the 2D group and the 3D group, respectively. In the 2D group, two patients revisited the outpatient clinic because of the postoperative occurrence of seroma and varicocele.

Conclusion

A 3D laparoscopic surgery is feasible and safe for inguinal hernia repair and showed less peritoneal tearing compared with 2D laparoscopic surgery for primary inguinal hernia repair.

Prosthetic meshes for hernia repair: State of art, classification, biomaterials, antimicrobial approaches, and fabrication methods

Worldwide, hernia repair represents one of the most frequent surgical procedures encompassing a global market valued at several billion dollars. This type of surgery usually requires the implantation of a mesh that needs the appropriate chemical, physical and biological properties for the type of repair. This review thus presents a description of the types of hernias, current hernia repair methods, and the state of the art of prosthetic meshes for hernia repair providing the most important meshes used in clinical practice by surgeons working in this area classified according to their biological or chemical nature, morphology and whether bioabsorbable or not. We emphasise the importance of surgical site infection in herniatology, how to deal with this microbial problem, and we go further into the future research lines on the production of advanced antimicrobial meshes to improve hernia repair and prevent microbial infections, including multidrug-resistant strains. A great deal of progress has been made in this biomedical field in the last decade. However, we are still far from an ideal antimicrobial mesh that can also provide excellent integration to the abdominal wall, mechanical performance, low visceral adhesion and minimal inflammatory or foreign body reactions, among many other problems.

Extended totally extraperitoneal Rives-Stoppa (eTEP-RS) technique for ventral hernia: initial experience of The Wall Hernia Group and a surgical technique update

The enhanced-view extended totally extraperitoneal (eTEP) approach for ventral hernia repair is a novel surgical technique. We present the results from the initial experience with eTEP repair Rives-Stoppa (eTEP-RS) at two Italian centers, and we provide an update on this approach. Between December 2018 and July 2020, 19 patients suffering from ventral hernia were treated with the eTEP-RS. Patients' characteristics, operative details, and complications were analyzed. The median follow-up time was 16 (range 6-24) months. Thirteen (68.4%) patients with ventral incisional hernias and 6 (31.6%) with primary ventral hernia underwent an eTEP-RS procedure. The average defect area was 21 cm² and the prosthesis's average size was 380 cm². We registered complications in two cases (10.5%); 1 patient had an asymptomatic seroma (Clavien-Dindo grade 1), and another had intestinal obstruction on the 10th postoperative day (Clavien-Dindo grade 3B). The mean hospital stay was 3.9 (range: 2-6) days. There was no hernia recurrence. The eTEP-RS is a feasible and safe approach in ventral hernia repair with minimally invasive surgery. Further studies are needed to define patients' selection and to know long-term outcomes.

Australian general surgical trainee experience with inguinal hernia surgery: a review of international training programmes and the learning curve

BACKGROUND

There are no publications addressing the level of experience Australian surgical trainees achieve in inguinal hernia surgery. Internationally, some training boards have set minimum competency requirements, but this is not true in Australia. The longer learning curve for laparoscopic inguinal hernia repairs (LIHRs) compared to open inguinal hernia repairs (OIHRs) has placed greater demands on trainees.

METHODS

Logbook data on OIHR and LIHR for Australian surgical trainees who graduated as fellows between 2013 and 2018 were obtained. A literature review was performed to analyse international published logbook numbers for surgical trainees from the past decade. International training board requirements, estimations of the learning curve and hernia society guidelines for each procedure were reviewed.

RESULTS

In total, 7946 operations were recorded from 58 trainees. On average 49.2 OIHRs (range 13-101), 21.5 LIHRs (range 1-94) and 71.1 inguinal hernia repairs overall (range 25-129) were performed during training. The European Hernia Society recommends that at least 30-50 of each procedure be performed during training. The learning curves for LIHRs (50-100 procedures) have been shown to be longer than for OIHRs (40-64 procedures).

CONCLUSION

Australian general surgical trainees are achieving adequate primary operator logbook numbers for OIHRs but are not completing the required number of LIHRs. The tailored approach to inguinal hernia repair requires skill in both open and laparoscopic repairs. This may not be possible with the current training structure in Australia.

Laparoscopic Pectopexy-CUSUM Learning Curve and Perioperative Complications Analysis

The study aimed to examine the learning curve and perioperative complications for laparoscopic pectopexy (LP). A total of 60 women with stage II–IV apical prolapse who underwent LP were dichotomized into groups: LSH(+) with concomitant laparoscopic supracervical hysterectomy (LSH), LSH(−) after previous supracervical/total hysterectomy. Operative time, estimated blood loss and hospitalization length were evaluated with cumulative sum (CUSUM) analysis and the Kwiatkowski–Phillips–Schmidt–Shin (KPSS) test, separately for two surgeons (A and B). Intraoperative and perioperative complications according to the Clavien–Dindo (C–D) classification were analyzed. Mean operative time, change in hemoglobin level, and postoperative hospital stay were 143.5 ± 23.1 min—1.5 ± 0.5g/dL and 2.5 ± 0.9 days, respectively. LSH during pectopexy was associated with longer operative time (p = 0.01) but not with higher intraoperative bleeding or prolonged hospital stay. Severe complications rate was low (1.7%) with one bowel injury in LSH(−) (C–D grade IIIb). No C–D grade II, IV and V complications were found. Conversion to open pectopexy, return to the operating room or blood transfusion were not required. The KPSS test showed that a steady operative time for Surgeon A was achieved after 28 procedures. A proficiency for laparoscopic pectopexy based on CUSUM analysis was observed after 38–40 procedures.

Learning curve analysis of robotic transabdominal preperitoneal inguinal hernia repair

BACKGROUND

The purpose of this study was to assess the learning curve (LC) for inguinal hernia repair with robotic transabdominal preperitoneal (R-TAPP) approach.

METHODS

Between April 2016 and October 2019, patients who underwent R-TAPP were retrieved. Patient demographics, operative variables and postoperative outcomes were assessed. The moving average method and cumulative sum of operation times (OT) were used to evaluate the LC. The surgeon (BB) in this study had completed his laparoscopic (Lap) TAPP experience.

RESULTS

There were 50 (two females) consecutive patients (mean age was 51.7 ± 16.9 years). The first phase (learning phase) included initial 35 operations. The second phase included the next 15 operations. It was observed that, with increasing experience, a statistically significant shortening in the average OT by about 25 min was achieved (p = 0.041).

CONCLUSION

The LC phase for R-TAPP, for surgeon with previous experience in Lap TAPP, seems to be very quick without compromising the operative morbidity.

Learning inguinal hernia repair? A survey of current practice and of preferred methods of surgical residents

Purpose

During surgical residency, many learning methods are available to learn an inguinal hernia repair (IHR). This study aimed to investigate which learning methods are most commonly used and which are perceived as most important by surgical residents for open and endoscopic IHR.

Methods

European general surgery residents were invited to participate in a 9-item web-based survey that inquired which of the learning methods were used (checking one or more of 13 options) and what their perceived importance was on a 5-point Likert scale (1 = completely not important to 5 = very important).

Results

In total, 323 residents participated. The five most commonly used learning methods for open and endoscopic IHR were apprenticeship style learning in the operation room (OR) (98% and 96%, respectively), textbooks (67% and 49%, respectively), lectures (50% and 44%, respectively), video-demonstrations (53% and 66%, respectively) and journal articles (54% and 54%, respectively). The three most important learning methods for the open and endoscopic IHR were participation in the OR [5.00 (5.00–5.00) and 5.00 (5.00–5.00), respectively], video-demonstrations [4.00 (4.00–5.00) and 4.00 (4.00–5.00), respectively], and hands-on hernia courses [4.00 (4.00–5.00) and 4.00 (4.00–5.00), respectively].

Conclusion

This study demonstrated a discrepancy between learning methods that are currently used by surgical residents to learn the open and endoscopic IHR and preferred learning methods. There is a need for more emphasis on practising before entering the OR. This would support surgical residents’ training by first observing, then practising and finally performing the surgery in the OR.

Electronic supplementary material

The online version of this article (10.1007/s10029-020-02270-y) contains supplementary material, which is available to authorized users.

A new semiresorbable mesh for primary inguinal repair: a preliminary observational study on quality of life and safety

BACKGROUND

A currently unsolved problem of open inguinal hernia repair (IHR) is chronic postoperative inguinal pain (CPIP), which affects 10-12% of patients after IHR. In the present paper, we explored the results of a newly designed partially absorbable mesh made of polypropylene and polylactic acid (HybridMesh^®) for open hernia repair and its impact on postoperative safety, efficacy, comfort and pain.

METHODS

A prospective multicentric pilot trial was conducted in third-referral centers across Italy (n = 5). Inclusion criteria were unilateral primary inguinal hernia in patients of both genders and BMI < 30 kg/m². All patients were submitted to elective Lichtenstein mesh hernia repair under local anesthesia with HybridMesh. Primary outcome measure was the evaluation of Carolina Comfort Scale and modifications at 2 years after surgery and its correlation with surgical variables; secondary outcomes were postoperative early and late morbidity, recurrence and postoperative early quality of life.

RESULTS

Between 2015 and 2016, 125 (5 female) patients were operated, 2-year follow-up rate was 100%. The surgical site occurrence rate was 28% without the need of procedural interventions. Twenty-four months after surgery, no case of severe CPIP was recorded and altered global CCS score was present in 16 patients (13.0%). At univariate analysis, CCS score was negatively affected by fixation with sutures (OR 3.949; 95% CI 1.334-13.300), with no effect shown on multivariate analysis. Alterations in pain and movement limitations domains of CCS were observed in 9.7% of patients, at univariate analysis; they occurred more frequently when the mesh was sutured (OR 4.437; 95% CI 1.387-17.025) and in patients suffering from SSO (ecchymosis: OR 3.269; 95% CI 1.032-10.405); however, no effect was shown on multivariate analysis. Two recurrences (1.6%) were identified within the first postoperative year.

CONCLUSIONS

The results of this study support the safety, efficacy and good tolerability of HybridMesh as a device to treat primary unilateral inguinal hernia during open anterior approach. Further studies are needed to clarify its role in comparison to currently available devices at longer follow-ups.

How I Do It: Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Inguinal hernia repair (IHR) is one of the most commonly performed general surgery operations. Currently, an inguinal hernia can be repaired through an open, laparoscopic, or robot-assisted approach. Herein, we detail our perioperative evaluation and management of patients with a groin hernia as well as our surgical technique for the performance of the laparoscopic transabdominal preperitoneal IHR.