Page 102 - International guidelines for groin hernia management

Hernia

However, another group reported marked differences in In the some European countries and the United States,
outcomes in relationship to individual surgeon’s volume at increase in surgical volume is often dependent on volume
three hospital types. So-called ‘‘occasional operators’’ agreements with health insurance companies.
dominated at university hospitals and had a significantly KQ23.d Does surgical specialization affect IH surgery
higher relative risk of recurrence compared with medium outcomes?

and small hospitals. 63 This finding supports the concept of It is difficult to separate surgeon caseload from special-
regionalization to specialized settings with high case vol- ization since they are highly correlated. The literature on
umes and greater experience. surgeon caseload is described above. A publication from
The impact of creating a surgical specialty referral one expert group opines ‘‘… there is a need for hernia
center has been studied as well, specifically the financial centers in which hernia surgery is practiced by specially
and institutional volume impact. 72 This study examined all accredited hernia surgeons who as far as possible master all
hernia repairs in the period 2004–2011 comparing hernia hernia surgical techniques and play an active role in
repair type, volume and center financial performance. The training and continuing education as well as in the field of
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ventral hernia repair (VHR) patient subset was further science. ’’ This statement goes a long way toward defining
analyzed for previous repairs, comorbidities, referral pat- a hernia specialist.
terns, and concomitant plastic surgery involvement. Prior Specialized hernia centers outperform general surgical
to hernia center establishment, hernia procedures averaged centers in laparoscopic and complex IH surgeries. 28, 55, 56
156 annually (years 1999–2003). Over the next 8-year Therefore, complex IH surgery should be performed by a
period, 4927 hernia repairs were performed with an aver- hernia specialist.
age of 616 hernia procedures per year. Annual billing In primary IH Lichtenstein repair, general surgeons’ and
increased yearly from 7 to 85% and averaged 37% per supervised-residents’ results were comparable with
year. Comparing 2004 with 2011, procedural volume experts’ results. 73, 74 Similar findings were found for
75, 76
increased 234%, and billing increased 713%. During that repairs with bilayer patches and plugs.
period, there was a 2.5-fold increase in open VHRs, and Hernia surgery specialization can significantly impact
plastic surgeon involvement increased almost eightfold, the type of hernia surgery performed in a region. Prior to
(p = 0.004). In 2005, 51 VHR patients had a previous year 2000, less than 1% of inguinal repairs were performed
repair, 27.0% with mesh, versus 114 previous VHR in laparoscopically in the Australian Capital Territory, pop-
2011, 58.3% with mesh (p \ 0.0001). For VHR, in-state ulation 400,000. Following the adoption and popularization
referrals from 2004 to 2011 increased 340% while out-of- of TEP repair in the state by a specialized hernia surgeon,
state referrals increased 580%. In 2011, 21% of all patients laparoscopic repairs increased annually to 39% in 2004.
had more than four comorbidities, significantly increased The value of hernia specialists developing and promul-
from 2004 (p = 0.02). It was concluded that the estab- gating new techniques and offering continuing education to
lishment of a tertiary/regional referral hernia repair center fellow surgeons and surgeons-in-training cannot be
led to a substantial increase in surgical volume, complex- underestimated.
ity, referral geography, and financial benefit to the
institution.

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