Does surgeon volume matter in the outcome of endoscopic inguinal hernia repair?

Abstract

IntroductionFor open and endoscopic inguinal hernia surgery, it has been demonstrated that low-volume surgeons with fewer than 25 and 30 procedures, respectively, per year are associated with significantly more recurrences than high-volume surgeons with 25 and 30 or more procedures, respectively, per year. This paper now explores the relationship between the caseload and the outcome based on the data from the Herniamed Registry.Patients and methodsThe prospective data of patients in the Herniamed Registry were analyzed using the inclusion criteria minimum age of 16 years, male patient, primary unilateral inguinal hernia, TEP or TAPP techniques and availability of data on 1-year follow-up. In total, 16,290 patients were enrolled between September 1, 2009, and February 1, 2014. Of the participating surgeons, 466 (87.6 %) had carried out fewer than 25 endoscopic/laparoscopic operations (low-volume surgeons) and 66 (12.4 %) surgeons 25 or more operations (high-volume surgeons) per year.ResultsUnivariable (1.03 vs. 0.73 %; p = 0.047) and multivariable analysis [OR 1.494 (1.065–2.115); p = 0.023] revealed that low-volume surgeons had a significantly higher recurrence rate compared with the high-volume surgeons, although that difference was small. Multivariable analysis also showed that pain on exertion was negatively affected by a lower caseload <25 [OR 1.191 (1.062–1.337); p = 0.003]. While here, too, the difference was small, the fact that in that group there was a greater proportion of patients with small hernia defect sizes may have also played a role since the risk in that group was higher. In this analysis, no evidence was found that pain at rest [OR 1.052 (0.903–1.226); p = 0.516] or chronic pain requiring treatment [OR 1.108 (0.903–1.361); p = 0.326] were influenced by the surgeon volume.SummaryAs confirmed by previously published studies, the data in the Herniamed Registry also demonstrated that the endoscopic/laparoscopic inguinal hernia surgery caseload impacted the outcome. However, given the overall high-quality level the differences between a “low-volume” surgeon and a “high-volume” surgeon were small. That was due to the use of a standardized technique, structured training as well as continuous supervision of trainees and surgeons with low annual caseload.

Hospital volume and outcome in inguinal hernia repair: analysis of routine data of 133,449 patients

“…In addition to the hernia-and patient-related influencing factors on the outcome of inguinal hernia surgery, those related to the surgeon volume and hospital volume are also being increasingly investigated [8][9][10][11][12][13][14]. For example, one analysis of data from the Danish Hernia Database revealed that hospitals with less than 50 inguinal hernia repairs per year were found to have a significantly higher rate of recurrence operations (9.97% vs 6.06%; p < 0.0001) compared with hospitals with 50 and more operations [9].…”

“…All the other aforementioned studies [8,[10][11][12][13] focused on the specific volume of an individual surgeon and its corresponding impact on the outcome. These studies have demonstrated that, as regards the surgeon volume, surgeons with higher caseloads have a lower recurrence rate [8,[10][11][12][13].…”

Primary inguinal hernia: The open repair today pros and cons

“…The learning curve for endoscopic techniques is estimated to be 50–100 cases, with the first 30–50 being the most critical, whereas the Lichtenstein technique is easier to teach and replicate at all levels. The outcomes of non‐experts and supervised residents performing the Lichtenstein repair for primary inguinal hernias are comparable to those of experts . For example, in our experience during the humanitarian mission, organized by Hernia Reapir For Underserved (HRFU), we adopted a validated competency‐based training program using the Operative Performance Rating Scale; after 364 procedures, 81 local surgeons successfully completed the program, and the overall operative complication rate during training series was 1.1% .…”

A 19 year population-based cohort study analysing reoperation for recurrence following laparoscopic and open inguinal hernia repairs

“…Recurrence is a key outcome in hernia surgery, and usually requires re-operation. Such re-operations are also associated with worse outcomes than primary repair [27][28][29].…”

“…There are few longitudinal studies comparing the need for surgery for recurrence between the two techniques and those that are available utilized data that are now historical [16,28]. Longitudinal assessments require careful consideration of competing risks.…”