Page 99 - International guidelines for groin hernia management

Hernia

• The development and learning of the techniques by Introduction
early independent pioneers in the 1990s should be Terms like ‘‘specialization’’ or ‘‘specialized centers’’ are
regarded separately from current structured surgical often undefined or poorly defined and rarely based on
training programs. scientific standards of excellence. The term ‘‘hernia center’’
and terms like it are frequently used as marketing tools. 52
Some surgeons find TAPP easier to learn than TEP. The
Studies on IH repair—with good results—are often pub-
data we reviewed on operative times and patient outcomes,
lished by surgeons specialized in hernia surgery.
however, do not strongly indicate that this is correct. It may
The definition of a hernia specialist requires objective
be that entry into the preperitoneal space from the more
parameters of expertise, annual case load, outcomes and
familiar intra-abdominal environment decreases the dis-
contributions to education and science. It is recommended
orientation in the preperitoneal space, or it may be that
that surgeons complete their learning curves in multiple
TAPP is indeed easier to learn.
techniques, thus facilitating a patient-specific approach to
Our statements and recommendations on how to teach
each individual dependent upon comorbidities and surgical
laparoscopic skills were based on a systematic review of
history. Most experienced hernia surgeons support the use
available studies that included a RCT on how to teach 53
of this patient-tailored approach (see Chapter 8).
laparoscopic hernia repair. The mastery training used in the
Recently, surgical procedures of various types have been
RCT did not close the gap to experts; it reduced it by a
qualified as ‘‘highly complex, low volume’’ and ‘‘low
clinically relevant decrease in complications.
complex, high-volume.’’ IH repair can reasonably be con-
Other lower quality studies revealed largely similar
sidered a high-volume procedure in the right setting. It has
results. There is, however, more available evidence on the
been shown that regular operating theater teams can
learning curve than on the teaching methods. As more
shorten room turnover times, preparation times and pro-
literature becomes available, the guidance on teaching 54
cedure times and thereby increase daily patient volumes.
methods may evolve as well.
The medical literature supports the notion that specialized
In preparing these statements we have accessed new,
centers with their high patient volumes achieve better
good quality and relevant research. Thus, our statements
results in laparoscopic and complex IH surgeries. The
and recommendations may update prior guidelines (e.g.,
51
EHS, 50 EAES ). In addition, as stated above we set category ‘‘complex IH surgery’’ includes: multiple recur-
28, 55, 56
rences, chronic pain, and mesh infection.
external benchmarks for the learning curve. For example,
As in other types of surgery, the incidence of surgical
the fact that a complication rate decreased by 50% after 50
complications is in large measure inversely related to a
cases was important; however, if the patient outcomes were
hernia surgeon’s annual caseload. This is particularly true
still lagged other options (e.g., open mesh repair as
for laparoscopic hernia repair. The learning curve for open
described in a large database) we did not describe the
IH repair is shorter (see Chapter 22 on Learning Curve).
learning curve as complete.
To improve IH repair outcomes, a continuous quality
We acknowledge that the statements and recommenda-
control and improvement cycle is recommended. Patient
tions may represent challenges for training programs.
follow-up should be organized to detect and register long-
Twenty-five years after the introduction of laparoscopic IH
and short-term complications. Active involvement in
repair, surgeons and surgical trainees have, however,
voiced concerns about being incompletely prepared. 36, 37 training, education and science and a broad and deep
clinical experience are essential for improving hernia sur-
Prior underestimation of the learning curve may have
gery care. Regionalization of hernia care at specialized
contributed to this unease.
centers is vital as well.
The ability to discern a ‘‘true hernia center’’ of excel-
lence from one with average experience and outcomes may
lie in certification of hernia surgery centers. A seminal
Chapter 23
article from 2014 described the process and goals of hernia
52
center certification in Germany. The article details that
two certification processes exist in Germany. The non-
Specialized centers and hernia specialists
profit organization Surgical Review Corporation uses the
designation, Certified Center of Excellence in Hernia
G. H. van Ramshorst, H. J. Bonjer, D. Cuccurullo, R.
Surgery (COEHS) while the German Hernia Society (GHS)
Bittner and H. M. Tran
and the German Society of General and Visceral Surgery
use the term Certified Hernia Center. 52
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