Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair?

Background

An important challenge of totally extraperitoneal (TEP) hernia repair is the learning curve. The European guidelines suggest that the learning curve ranges between 50 and 100 procedures, with the first 30–50 being critical. Others suggest that optimal outcomes are achieved after 200 or more TEP procedures.

Methods

All TEP repairs performed between 2005 and 2009 were included in this study. The effect of (surgeon) expertise on perioperative complications, conversion to open anterior repair, and operative time was assessed to evaluate the extent of the learning curve of TEP repair.

Results

Intraoperative complications occurred in <1 % of the 3,432 patients and postoperative complications were observed in 243 (7 %) patients. With a median follow-up of 2 years after TEP, 19 patients (0.55 %) had a recurrence. During the study period, at the end of which all four surgeons had treated 900–1,000 patients, intraoperative complications and recurrences did not decline. On the other hand, the median operative time decreased from 30 to 20 min (p < 0.001). The conversion rate (1.6–0.2 %, p = 0.018) and postoperative complication rate (11.6–4.2 %, p < 0.001) also declined. The decline was observed for all four surgeons, irrespective of their initial expertise with TEP. The largest decrease in the conversion rate was seen after at least 250 TEP procedures; the postoperative complication rate and operative time showed a linear and significant decline throughout the study period. A more or less “steady state” was observed after approximately 450 procedures per surgeon.

Conclusions

Even after more than 400 individually performed TEP procedures, there is progress in reducing the conversion rate, the incidence of short-term postoperative complications, and operative time, indicating a rather long learning curve.     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

Is endoscopic totally extraperitoneal hernioplasty justified for the repair of groin hernia in female patients?

Background Groin hernia is an uncommon surgical pathology in females. The efficacy of the endoscopic approach for the repair of female groin hernia has yet to be examined. The current study was undertaken to compare the clinical outcomes of female patients who underwent open and endoscopic totally extraperitoneal inguinal or femoral hernioplasty (TEP). Methods From July 1998 to June 2004, 108 female patients who underwent elective repair of groin hernia were recruited. The patients were divided into TEP (n = 30) and open groups (n = 78) based on the type of operation. Clinical data and outcome parameters were compared between the two groups. Results The mean ages and hernia types were comparable between the two groups. All TEPs were successfully performed. The mean operative times were 52 min for unilateral TEP and 51 min for open repair. The difference was not statistically significant. Comparisons of the length of hospital stay, postoperative morbidity, pain score, and time taken to resume normal activities showed no significant differences between the two groups. A single patient in the TEP group experienced recurrence of hernia. Conclusions The findings show equivalent postoperative outcomes after TEP and open repair of groin hernia in female patients. Because the wound scar after open repair is well concealed beneath the pubic hair and no superior clinical benefits are observed after TEP, open repair appears to be the technique of choice for the management of primary groin hernia in females. The TEP approach should be reserved for female patients with recurrent or multiple groin hernia. The abstract was presented at the Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2005, 13–16 April 2005 at Fort Lauderdale, Florida     

TEP or TAPP for recurrent inguinal hernia repair—register-based comparison of the outcome

Introduction

The guidelines of the international hernia societies recommend laparo-endoscopic inguinal hernia repair for recurrent hernias after open primary repair. To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. A Swiss registry study identified only minor differences between the two techniques, thus suggesting the equivalence of the two procedures.

Materials and Methods

Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n?=?1,464) or TEP technique (n?=?782).

Results

Univariable and multivariable analysis did not find any significant difference between TEP and TAPP with regard to the intraoperative complications, complication-related reoperations, re-recurrences, pain at rest, pain on exertion, or chronic pain requiring treatment. The only difference identified was a significantly higher postoperative seroma rate after TAPP, which was influenced by the surgical technique, previous open primary operation and EHS-classification medial and responded to conservative treatment.

Conclusion

TEP and TAPP are equivalent surgical techniques for recurrent inguinal hernia repair following previous open primary operation. The choice of technique should be tailored to the surgeon’s expertise.

     

Outpatient groin hernia repair: assessment of 9330 patients from the French “Club Hernie” database

Background

Groin hernia repair (GHR) is one of the most frequent surgical interventions practiced worldwide. Outpatient surgery for GHR is known to be safe and effective.

Aim

To assess the outpatient practice for GHR in France and identify predictive factors of failure.

Method

Forty one surgeons of the French “Club Hernie” prospectively gathered data concerning successive GHR over a period of 4 years within a multicenter database.

Results

A total of 9330 patients were operated on during the period of the study. Mean age was 61.8 (1–100) years old and 8245 patients (88.4%) were males. 6974 GHR (74.7%) were performed as outpatient procedures. In 262 patients (3.6%), the outpatient setting, previously selected, did not succeed. Upon multivariate analysis, predictive factors of ambulatory failure were ASA grade ≥ III (OR 0.42, p < 0.001), bilateral GHR (OR 0.47, p < 0.001), emergency surgery for incarcerated hernia (OR 0.10, p < 0.001), spinal anesthesia (OR 0.27, p < 0.001) and occurrence of an early post-operative complication (OR 0.07, p < 0.001). The more frequent complications were acute urinary retention and surgical site collections. 2094 patients (21.5%) were not selected preoperatively for 1-day surgery.

Conclusion

More than 74% of the patients benefited from outpatient surgery for GHR with a poor failure rate. Predictive factors of outpatient GHR failure were ASA grade ≥ III, bilateral GHR, emergency surgery for incarcerated hernia, spinal anesthesia and occurrence of an early post-operative complication. Ambulatory failures were often related to social issues or medical complications. Outpatient surgery criteria could become less restrictive in the future.

     

Characterizing the learning curve of the VBLaST-PT© (Virtual Basic Laparoscopic Skill Trainer)

Background

Mastering laparoscopic surgical skills requires considerable time and effort. The Virtual Basic Laparoscopic Skill Trainer (VBLaST-PT^©) is being developed as a computerized version of the peg transfer task of the Fundamentals of Laparoscopic Surgery (FLS) system using virtual reality technology. We assessed the learning curve of trainees on the VBLaST-PT^© using the cumulative summation (CUSUM) method and compared them with those on the FLS to establish convergent validity for the VBLaST-PT^©.

Methods

Eighteen medical students from were assigned randomly to one of three groups: control, VBLaST-training, and FLS-training. The VBLaST and the FLS groups performed a total of 150 trials of the peg-transfer task over a 3-week period, 5 days a week. Their CUSUM scores were computed based on predefined performance criteria (junior, intermediate, and senior levels).

Results

Of the six subjects in the VBLaST-training group, five achieved at least the “junior” level, three achieved the “intermediate” level, and one achieved the “senior” level of performance criterion by the end of the 150 trials. In comparison, for the FLS group, three students achieved the “senior” criterion and all six students achieved the “intermediate” and “junior” criteria by the 150th trials. Both the VBLaST-PT^© and the FLS systems showed significant skill improvement and retention, albeit with system specificity as measured by transfer of learning in the retention test: The VBLaST-trained group performed better on the VBLaST-PT^© than on FLS (p = 0.003), whereas the FLS-trained group performed better on the FLS than on VBLaST-PT^© (p = 0.002).

Conclusions

We characterized the learning curve for a virtual peg transfer task on the VBLaST-PT^© and compared it with the FLS using CUSUM analysis. Subjects in both training groups showed significant improvement in skill performance, but the transfer of training between systems was not significant.     

Elective neurectomy during open, “tension free” inguinal hernia repair

Chronic postoperative inguinal pain syndromes are potentially debilitating sequelae following elective inguinal hernia repair. Diagnosis and definitive treatment constitute challenging issues for both the surgeon and the patient. In this prospective trial, we evaluated the impact of elective iliohypogastric and ilioinguinal nerve resection on the incidence of pain, numbness, and sensory loss following anterior, tension-free herniorrhaphy. One hundred ninety-one patients were enrolled and were reviewed 1 month, 6 months, and 1 year postoperatively. Pain, numbness, or any loss of sensation were recorded and categorized on a mild, moderate, or severe scale. No persistent pain syndrome was encountered. Numbness was found in 9.42% of the patients at the first month and in 6.28% of the patients after 1 year. Sensation loss (1.04%) was never bothersome or incapacitating at the end of the follow-up period. Elective neurectomy is safe to perform, well tolerated by patients, and is not associated with chronic postoperative inguinal pain.     

The “learning curve” of total hip arthroplasty

Total hip arthroplasty (THA) is one of the major breakthroughs in modern orthopedics this century. Since its introduction in the early 1960s by Sir J. Charnley, it has become the most common form of arthroplasty. The art of performing THA has developed to a large extent, yet with the inevitable price of a learning curve. The rates of early and late complications reported in the orthopedic literature have been decreasing gradually, along with improved short- and long-term results. We report the results of two similar series of THA performed with an interval of 15 to 20 years, which show that the improvement of the results that form the learning curve of THA at our institution is statistically significant.     

The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients’ perspective

Hernia - Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among...     

Totally extraperitoneal (TEP) bilateral hernioplasty using the Single Site® robotic da Vinci platform (DV-SS TEP): description of the technique and preliminary results

Purpose

Laparoendoscopic single site totally extraperitoneal (TEP) hernia repair showed to be a feasible alternative to conventional laparoscopic hernia repair; nevertheless single site surgery, with the loss of instruments triangulation can be a demanding procedure. To overcome those hurdles, the Single Site® (SS) platform of the da Vinci (DV) Si robotic system enables to perform surgical procedures through a 25-mm skin incision, with a stable 3D vision and restoring an adequate triangulation of the surgical instruments. We present in details the technique and the preliminary results of DV-SS TEP, to our knowledge the first cases reported in literature.

Methods

In March 2016, three consecutive male patients (mean age 46.6 years–mean BMI 25.3) with bilateral symptomatic inguinal hernia were submitted to DV-SS TEP in our institutions. Feasibility, codification of the technique, operative time and perioperative outcomes were recorded.

Results

All the procedures were completed as scheduled, with no conversion to other techniques. Mean operative time was 98.6 min, ranging between 155 and 55 min, reflecting the learning curve of the operating room team on this new procedure. No intraoperative or postoperative complications were experienced and all the patients were discharged within 24 h after surgery. Patients reported satisfactory postoperative course, with no recurrence of inguinal hernia and satisfaction in cosmetic result at 6-month follow-up.

Conclusions

DV-SS TEP inguinal hernia repair showed to be feasible and effective surgical option for bilateral groin hernia repair. Patients’ outcome was uneventful, with optimal cosmetic results. Further studies comparing this innovative technique to TEP or LESS TEP should be promoted.

     

Laparoscopic ventral hernia repair in the elderly: does the type of hernia matter?

Purpose

Assess the impact of age and type of hernia on the outcomes of laparoscopic ventral hernia repair (LVHR).

Methods

Operating room database of all laparoscopic ventral hernias performed from April 2001 to July 2010 was analyzed retrospectively. Patients were divided into two groups: primary hernias (Group 1) and incisional hernias (Group 2). These groups were further stratified into patients <65?years of age (Groups 1A and 2A) and patients >65?years of age (Groups 1B and 2B). Patient demographics, hernia characteristics, perioperative outcomes, and disposition at discharge were compared. p-values <0.05 were considered significant.

Results

325 patients, with a mean age of 56.6?years (24–93?years) underwent LVHR. The mean length of stay (LOS) was longer (2.7?days vs 1.7?days, p value?=?0.02), and the rate of same day discharge was also significantly lower (12 vs. 25?%, p?=?0.02) for Group 2B when compared to Group 2A. Three patients in Group 2B, who had been living independently, were discharged to a skilled nursing facility, which proved significantly different when compared with Group 2A. There was no statistically significant difference in perioperative outcomes between younger and older subgroups with primary hernias.

Conclusions

LVHR in the elderly with incisional hernias have longer LOS and have a higher need for post-discharge nursing care unlike their counterparts with primary hernias. Identifying this cohort of patients early on helps the health-care providers to optimize the outcomes.     

Laparoscopic repair of incisional hernia in solid organ‐transplanted patients: the method of choice?

Due to immunosuppressive (IS) therapy, incisional hernias are overrepresented in the organ‐transplanted (Tx) population with larger defects, a high rate of recurrence, and a tendency toward more seromas and infectious problems. Thirty‐one Tx/IS patients with a control group of 70 non‐IS patients with incisional hernia (6/7 recurrences) were included in a prospective interventional study. Both cohorts were treated with laparoscopic ventral hernia repair (LVHR). Follow‐up time and rate was 37 months and 95%. One hundred LVHR's were completed as there was one conversion in the Tx/IS group. No late infections or mesh removals occurred. Recurrence rates were 9.7% vs. 4.2% (P = 0.37) and the overall complication rates were 19% vs. 27% (P = 0.80). The Tx/IS group had a higher mesh‐protrusion rate (29% vs. 13%, P = 0.09), but also larger hernias. Polycystic kidney disease was overrepresented in the Tx cohort (44% of kidney‐Tx). Incisional hernias in Tx/IS patients may be treated by LVHR with the same low complication rate and recurrence rate as non‐IS patients. By LVHR, the highly problematic seroma/infection problems encountered in Tx/IS patients treated by conventional open technique seem almost eliminated. The minimally invasive procedure seems particularly rational in the Tx/Is population and should be the method of choice. (ClinicalTrials.gov number: NCT00455299, date: 5 May 2006).