“Happy to close?” The relationship between surgical experience and incisional hernia rates following abdominal wall closure in colorectal surgery

Abstract

Aim Incisional hernia (IH) is a common complication of colorectal surgery, affecting up to 30% of patients at 2 years. Given the associated morbidity and high recurrence rates after attempted repair of IH, emphasis should be placed on prevention. There is an association between surgeon volume and outcomes in hernia surgery, yet there is little evidence regarding impact of the seniority of the surgeon performing abdominal wall closure on IH rate. The aim of our study was to assess the rates of IH at 1 year following abdominal wall closure between junior and senior surgeons in patients undergoing elective colorectal surgery. Methods This was an exploratory analysis of patients who underwent elective surgery for colorectal cancer between 2014–2018 as part of the Hughes Abdominal Repair Trial (HART), a prospective, multicentre randomised control trial comparing abdominal wall closure methods. Grade of surgeon performing abdominal closure was categorised into “trainee” and “consultant” and compared to IH rate at one year. Results A total of 663 patients were included in this retrospective analysis of patients in the HART trial. The rate of IH in patients closed by trainees was 20%, compared to 12% in those closed by consultants (p = <0.001). When comparing closure methods, IH rates were significantly higher in the Hughes closure arm between trainees and consultants (20% vs. 12%, p = 0.032), but not high enough in the mass closure arm to reach statistical significance (21% vs. 13%, p = 0.058). On multivariate analysis, age (p = 0.036, OR: 1.02, 95% CI: 1.00–1.04), Male sex (p = 0.049, OR: 1.61, 95% CI: 1.00–2.59) and closure by a trainee (p = 0.006, OR: 1.85, 95% CI: 1.20–2.85) were identified as risk factors for developing IH. Conclusion Patients who undergo abdominal wall closure by a surgeon in training have an increased risk of developing IH when compared to those closed by a consultant. Further work is needed to determine the impact of supervised and unsupervised trainees on IH rates, but abdominal wall closure should be regarded as a training opportunity in its own right.

Incisional hernias: epidemiology, evidence and guidelines

“…Die Standardisierung ist daher ein unumgängliches Kriterium für eine Vergleichbarkeit wissenschaftlicher Studien [ 22 ]. Darüber hinaus bleibt der größte Risikofaktor für einen unkomplizierten Verlauf des Mittellinienverschlusses neben vielen anderen Faktoren immer noch der Chirurg und seine Expertise selbst, wie bereits aus einer Studie aus dem Jahr 1998 [ 23 ] und einer rezent publizierten Studie ersichtlich ist [ 24 ].…”

Editor's Choice – June 2023

“…Within colorectal surgery specifically, there is often an emphasis on technical steps such as patient positioning, exposure, mobilisation, vascular ligation etc when training. In this edition of Colorectal Disease Smith et al ask whether the final step of any colorectal resection – abdominal closure – is a technical step in its own right that impacts on the incidence of incisional hernia [1]. This sub‐analysis of data from the recently published NIHR HART study [2] highlights that incisional hernia rates are higher in those patients in whom the midline incision was closed by a trainee as opposed to a consultant surgeon.…”