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Analysis of outcome of Lichtenstein groin hernia repair by surgeons in training versus a specialized surgeon
Linköping University, Department of Clinical and Experimental Medicine, Surgery. Linköping University, Faculty of Health Sciences.
Department of Surgery, Västervik Hospital, Västervik, Sweden.
Linköping University, Department of Clinical and Experimental Medicine, Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Östergötland.
Department of Surgery, Department of Gastrointestinal Surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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2011 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9294, Vol. 15, no 3, 281-288 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: Groin hernia repair is a common procedure in general surgery, and is taught to and performed by surgeons early in their training. The aim of this observational study was to compare hernia repair performance and results of surgical trainees with those of a specialized surgeon. The further aim sought to identify what factors may influence short and long-term outcome, and areas for improvement in surgical training.

Methods: A non-randomized parallel cohort study was designed to compare a specialized surgeon with surgical trainees, performing the Lichtenstein repair in adult males. Two hundred repairs were included, of which 96 were performed by surgical trainees. Patient characteristics, surgical experience, and operative data including duration of procedural parts and surgical complexity were noted at surgery. Postoperative complications, recurrence, chronic pain and residual symptoms were assessed at longterm follow-up after a median of 34.5 months.

Results: Surgical trainees had longer overall operative time consume, with an unproportionally longer time for mobilising the sac and cord. They perceived exposure and mobilisation as more difficult than the specialist, and also a greater demand on own experience during surgery. The trainee repairs had a higher rate of postoperative complications (14.7% versus 5.0%) but recurrence rate was the same as for specialist repairs. At long-term follow-up, specialist repairs had a higher symptom burden and more chronic pain.

Conclusions: Comparison of a specialized surgeon to surgical trainees in performance and outcome for inguinal hernia surgery shows it was more efficient, but not necessarily better to let a specialized surgeon perform the repairs. The better long-term outcome for surgical trainees stands in contrast to the prejudice that it is better to have an experienced surgeon to perform standard procedures. It seems likely that targeted training in dissection and mobilisation could decrease level of perceived complexity and shorten operative time consume for surgical trainees. We believe that adequately supervised hernia surgery should remain as a part of the surgical training.

Place, publisher, year, edition, pages
Springer , 2011. Vol. 15, no 3, 281-288 p.
Keyword [en]
Groin hernia, Surgical trainees, Lichtenstein, Pain
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-63643DOI: 10.1007/s10029-010-0780-yISI: 000291603300006OAI: diva2:382058
Available from: 2010-12-29 Created: 2010-12-29 Last updated: 2012-05-09
In thesis
1. Audit of Groin Hernia Repair II
Open this publication in new window or tab >>Audit of Groin Hernia Repair II
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Groin hernia repair is one of the most common operations performed in general  surgery, and every fourth man is expected to have a hernia operation during his lifetime. Although 8% of all repairs are performed in women, there is little published literature relating specifically to female anatomy, risk factors and techniques. There is a continuing development of new mesh materials and health care reorganization with specialized surgical clinics changing the availability of basic surgery for surgeons under training.

In 1997 a thesis was published by Anders Kald, Audit of Groin Hernia Repair, which aimed to establish an audit of hernia surgery, evaluating management, risk factors, outcome and economy. The aim of this thesis was to continue the audit of hernia surgery in Sweden, allowing evaluation of gender issues, a new mesh material, and performance of surgeons under training.

Our data showed that women have a higher incidence of emergency groin hernia repair than men, and an increased rate of femoral recurrence after an inguinal hernia repair. Time to reoperation suggests that a primary misdiagnosis is common. Detection of femoral hernias could be increased by using preperitoneal techniques, visualizing all three groin hernia locations.

Patients who received a lightweight mesh at their hernia operation had a shorter convalescence, with faster return to work and normal activity.

It might be more efficient, but not necessarily better to let a specialized hernia surgeon perform the repair. Surgical trainees had more postoperative complications, but fewer patients had chronic pain at the long-term follow-up.

Abstract [sv]

Ljumskbråcksoperationen är en av de vanligaste operationerna inom allmänkirurgi och var fjärde man förväntas bli opererad för ett bråck under sin livstid. Trots att 8% av alla operationer utförs på kvinnor, finns det sparsamt med litteratur publicerat som rör kvinnlig anatomi, riskfaktorer och operationstekniker. Det utvecklas kontinuerligt nya nätmaterial och omorganisationer inom sjukvården med specialiserade kirurgiska kliniker har förändrat tillgängligheten på allmänkirurgi för kirurger under utbildning.

1997 publicerade Anders Kald sin avhandling, Audit of Groin Hernia Repair, vilken hade som syfte att etablera en kvalitetssäkring av bråckkirurgin, med utvärdering av handläggning, riskfaktorer, resultat och ekonomi. Syftet med denna avhandling var att fortsätta kvalitetssäkra bråckkirurgin i Sverige, med utvärdering av genusfrågor, ett nytt nätmaterial och prestationen hos kirurger under utbildning.

Våra data visade att kvinnor har högre incidens av akut bråckoperation än män, och ökad frekvens av femoralbråcksrecidiv efter en inguinalbråcksoperation. Tiden till reoperation tyder på en initial feldiagnos och preperitoneala tekniker rekommenderas för att öka identifieringen av femoralbråck.

Patienter som fått ett lättviktsnät vid sin bråckoperation hade en kortare konvalesens med snabbare återgång till arbete och normala aktiviteter.

Det kan vara effektivare, men inte nödvändigtvis bättre att låta en specialiserad bråckkirurg att utföra operationen. Kirurger under utbildning hade fler postoperativa komplikationer, men färre patienter med kronisk smärta vid långtidsuppföljningen.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2010. 45 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1221
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-63645 (URN)978-91-7393-262-2 (ISBN)
Public defence
2010-12-15, Katastrofmedicinskt centrum, Hälsouniversitetet, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)

On the day of the defence date the title of article III was: "Groin hernia repair with Titanium Coated Mesh compared to Prolene Mesh: A Prospective Randomized Controlled Trial".

Available from: 2010-12-29 Created: 2010-12-29 Last updated: 2015-06-05Bibliographically approved

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Koch Frisén, AngelicaStarck, JoachimSmeds, StaffanKald, Anders
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