What Is the Influence of Simulation-Based Training Courses, the Learning Curve, Supervision, and Surgeon Volume on the Outcome in Hernia Repair?—A Systematic Review

Abstract

Introduction: In hernia surgery, too, the influence of the surgeon on the outcome can be demonstrated. Therefore the role of the learning curve, supervised procedures by surgeons in training, simulation-based training courses and surgeon volume on patient outcome must be identified.Materials and Methods: A systematic search of the available literature was carried out in June 2018 using Medline, PubMed, and the Cochrane Library. For the present analysis 81 publications were identified as relevant.Results: Well-structured simulation-based training courses was found to be associated with a reduced perioperative complication rate for patients operated on by trainees. Open as well as, in particular, laparo-endoscopic hernia surgery procedures have a long learning curve. Its negative impact on the patient can be virtually eliminated through consistent supervision by experienced hernia surgeons. However, this presupposes availability of an adequate trainee caseload and of well-trained hernia surgeons and calls for a certain degree of centralization in hernia surgery.Conclusion: Training courses, learning curve, supervision, and surgeon volume are important aspects in training and outcomes in hernia surgery.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

“…It is well recognized that laparo-endoscopic surgical techniques are associated with a longer learning curve because of their increased complexity and skill required [19]. For example, the learning curve in the TEP technique for inguinal hernia repair may require up to 250 procedures, especially when taking into account all the outcome criteria [19]. For TAPP the learning curve is seen as approximately 50-100 procedures [19].…”

“…For example, the learning curve in the TEP technique for inguinal hernia repair may require up to 250 procedures, especially when taking into account all the outcome criteria [19]. For TAPP the learning curve is seen as approximately 50-100 procedures [19]. Notwithstanding the higher learning curve in TEP and TAPP, the open mesh and non-mesh procedures also have a relevant and defined learning curve [19] which, if not followed correctly, could result in high recurrence and/or chronic pain rates [19].…”

“…Notwithstanding the higher learning curve in TEP and TAPP, the open mesh and non-mesh procedures also have a relevant and defined learning curve [19] which, if not followed correctly, could result in high recurrence and/or chronic pain rates [19]. The laparoscopic IPOM technique in incisional hernia repair is associated with a recognized considerably higher complication rate, especially during the learning curve and therefore there is a strong recommendation that training in this operation is always under close supervision [19]. At present there are unfortunately no data available as such on the expected or recommended learning curve for the open surgical techniques used for incisional hernia repair [19].…”

“…The laparoscopic IPOM technique in incisional hernia repair is associated with a recognized considerably higher complication rate, especially during the learning curve and therefore there is a strong recommendation that training in this operation is always under close supervision [19]. At present there are unfortunately no data available as such on the expected or recommended learning curve for the open surgical techniques used for incisional hernia repair [19]. But it can be assumed that the open techniques, such as the sublay operation, open IPOM and the component separation techniques, are associated with significantly longer learning curves than inguinal hernia repairs.…”

“…Hence, implementation of any 'tailored' approach with 'mastery' and expertise developed in many operative procedures in abdominal wall surgery to come in line with the current guidelines will invariably significantly add to the already increasing demands on any surgeon. Appropriate training in line with the guidelines will generally rely on extensive training under the supervision of an experienced abdominal wall surgeon rather than on an ad hoc approach which can be assumed to be commonly employed in most general surgical training environments [19].…”