Page 101 - International guidelines for groin hernia management

Hernia

KQ23.b Do surgical volumes affect the outcomes of IH Few studies have compared high-volume surgeons’
surgeries? outcomes with low-volume surgeons’ outcomes. Some

A Swedish Hernia Registry study found that surgeons studies have compared open IH repairs by residents with
who performed one to five hernia repairs annually (any repairs by full-trained surgeons. In one study, residents
technique) had longer operation times and significantly took more time to dissect and mobilize the sac and had
higher reoperation rates than surgeons who did more significantly higher postoperative complication rates.
repairs. 63, 64 An NHS study found comparable results; Recurrence rates, however, were similar. More chronic
surgeons’ annual laparoscopic hernia repair caseload was pain occurred in the specialist-repair group. 69
inversely related to reoperation rates following laparo-
65 KQ23.c Does facility specialization affect IH surgery
scopic repair of primary IH. This was not the case for
outcomes?
open repair. This study contained no information on sur-
Emerging evidence suggests that high center volume is
geons’ laparoscopic experience. The summed evidence
related to positive outcomes for a wide variety of surgical
suggests that higher case load correlates positively with
fewer recurrences following primary laparoscopic IH procedures and that reducing the number of centers
undertaking complex surgical procedures is associated with
repair.
better outcomes.
A large RCT compared laparoscopic with open IH repair
Complex IH repairs include those with re-recurrences,
and found a 10.1% recurrence rate following laparo-
scopy. 66 In the study, 69 surgeons performed 989 repairs. chronic pain or mesh infections. However, there are no
studies comparing specialist with non-specialist center
Prior to the study’s commencement, only 20 of the sur-
repairs of these cases.
geons self-reported an experience of more than 250 repairs.
Some have suggested that good outcomes in complex
For this highly experienced group, the recurrence rate for
cases result from the aggregate effect of surgical expertise,
laparoscopic repair of primary hernia dropped to 5.1% and
high volumes, choice of more effective treatment modali-
was comparable to recurrence rate after open repair at
ties and other factors unrelated to surgical expertise. There
4.1%. The authors concluded that an experience of 250 IH
repairs was necessary to achieve a significant reduction in may also be benefits of working with a highly skilled team
that performs complex tasks repeatedly, has good knowl-
recurrence rates. They defined a new category, ‘‘highly
edge of different techniques for abdominal wall repair and
experienced surgeons’’ as those who had performed more
possesses extensive experience in the entire field of hernia
than 250 IH repairs.
surgery. There may be a need for hernia centers that offer
A survey found that routine surgical practice varied with
‘‘a complete hernia service’’ using a ‘‘tailored approach’’. 52
hernia surgery volume. Surgeons who performed more than
The National Outcomes Program established in 2009,
50 repairs annually were more likely to visualize and
67 evaluates healthcare outcomes in Italian hospitals and
preserve inguinal nerves, a measure recommended for
assesses the UK’s National Health System (NHS). In
prevention of chronic pain. It is reasonable to assume that
addition to outcomes, the 2013 Program edition included a
high-volume surgeons are more focused on chronic pain
set of volume indicators for conditions with evidence of a
prevention. Notably though, this study did not document
chronic pain incidence in relation to surgical volume. volume-outcome association. However, due to a paucity of
evidence, it is not possible to draw firm conclusions about
A review article noted that recurrence rates after 70
hernia treatment from this data set.
Shouldice repair by hernia specialists (term not defined in
Another trial was also unable to establish a clear rela-
the article) were lower when compared with repairs by
tionship between high-volume hernia centers and improved
non-specialists. Wound infection rates were comparable 71
between the groups. 68 outcome.
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