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

Abstract

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.

Surgical outcomes of laparoscopic total extraperitoneal (TEP) inguinal hernia repair compared with Lichtenstein tension-free open mesh inguinal hernia repair: A prospective randomized study

“…[15] The learning curve of laparoscopic hernia surgery is longer as reported in the various literature. [16][17][18][19] Table 6 shows comparison of operative time in various studies as described in the literature. [20][21][22][23][24] In the laparoscopic TEP group, the main intraoperative complication was the accidental creation of pneumoperitoneum, which occurred in 13 cases (14.7%), later managed by insertion of Veress needle/5-mm port at Palmer's point to decompress the pneumoperitoneum.…”

“…[15] The learning curve of laparoscopic hernia surgery is longer as reported in the various literature. [16–19] Table 6 shows comparison of operative time in various studies as described in the literature. [20–24]…”

Surgical Treatment of Recurrent Inguinal Hernia: The Choice of Method

“…Ця різниця у тривалості операції статистично недостовірна, хоча зниження часу за лапароскопічного утручання було чітко проявлене. Необхідно відзначити, що для успішного виконання лапароскопічної пластики рецидивних пахових гриж необхідна наявність досвіду хірурга [9]. Під час визначення частоти ранніх і пізніх ускладнень нами виявлено статистично достовірно (р<0,01) менше ускладнень після лапароскопічної герніоплатики, ніж після відкритої.…”

Does medical benefit schedule (MBS) accurately reflect operative challenges of laparoscopic versus open inguinal hernia repair (IHR)?

“…This may be attributed to the more substantial learning curve compared to the open approach. 4 Consolidation of MBS coding for laparoscopic and open IHR provides several pertinent future implications. Firstly, the lack of remuneration incentive for laparoscopic IHR may limit motivation for public and private health care sectors to continue performing the laparoscopic approach.…”

“…This may result in poor surgical training, indeed, Australian surgical trainees are not yet exposed to enough case volume to overcome that learning curve required for laparoscopic IHR. 4 Secondly, future exploratory studies and Federal MBS reviews are required to study the differences between laparoscopic and open IHR. Such reviews would be prohibited based on the consolidation of MBS item numbers.…”