Elsevier

Ambulatory Surgery

Volume 10, Issue 3, December 2003, Pages 143-146
Ambulatory Surgery

Groin hernia repair under local anaesthesia: effect of surgeon's training level on long-term results

https://doi.org/10.1016/j.ambsur.2003.06.001Get rights and content

Abstract

Tension-free Lichtenstein procedure was performed as an outpatient procedure under local anaesthesia in 317 patients. One senior consultant operated on 182 hernias and 12 surgical trainees on 135 hernias during 1996–2000. After a mean follow-up of 3 years, a postal questionnaire was sent to the patients. The operative outcome (operation time, pain, bleeding, infections) and long-term results (recurrences, chronic pain) were recorded. The rate of wound infections (consultant 1.1%, residents 0.7%) and hematomas (consultant 1.1%, residents 3.0%) were low and not related to the surgeon's training level. Only five recurrences were found at follow-up: two after consultant and three after trainee repair. Although 25% of the patients reported some groin pain afterwards, over 90% were very satisfied with the operation. Open mesh repair under local anaesthesia is cost-effective, simple and a safe operation. The learning curve was relatively short and there was no difference in the long-term outcome between the trainees and their consultant.

Introduction

Inguinal hernias occur in about 16% of adult men and herniorraphy is one of the top three surgical procedures in most western countries [1]. Approximately 12 000 inguinal herniorraphies are performed each year in Finland and over 80 000 operations in UK [1], [2]. The majority of groin hernias are currently operated on in ambulatory surgery units. About 20% of groin hernia repairs are undertaken for recurrences and 4% as an emergency [3]. Therefore, the socioeconomical impact of groin hernia surgery is high on health care system.

There is strong evidence that surgeon's case volume, hospital volume and specialisation improve the outcome of major surgical procedures, such as coronary artery bypass, gastrectomy, oesophagectomy, arthroplasty and rectal cancer surgery [4], [5]. The role of specialist centres in more common surgical operations, such as colon resections or inguinal herniorraphies, is not so clear [3], [6]. Although inguinal herniorraphy is one of the first operations performed by surgical trainees, few studies have compared the operative results between trainees and consultants.

Lichtenstein hernioplasty is a tension-free technique, which uses polypropylene mesh to support the inguinal muscular layers [7]. Its learning curve is even shorter than traditional groin hernioplasties, and, therefore, the Lichtenstein procedure has rapidly increased as a primary operation for inguinal hernias. In some countries the rate of the Lichtenstein operation is over 50% of all inguinal hernia surgery [3]. Under local anaesthesia it can be performed as a rapid outpatient procedure with cost savings. The present study was designed as a quality control audit in the surgical training programme for this common surgical procedure. The main interest was whether young surgical trainees can perform the Lichtenstein operation with an acceptable immediate and long-term outcome compared with an experienced specialist in hernia surgery.

Section snippets

Materials and methods

This was an observational study of one hospital during the years 1996–2000. Our hospital is a non-university teaching hospital with six to eight surgical trainees working at the same time. In Finland, the general surgical training consists of 2.5–3 years serving in a central provincial hospital and thereafter 3 years subspecialisation at the university hospital. The annual number of inguinal herniorraphies in our hospital has varied between 180 and 200 (population 110 000). The tension-free

Results

The patient characteristics were similar in both groups (Table 1). Consultant mean operative time was shorter than the trainees. There were no differences in the number of recurrent hernias or severe wound complications between the consultant and the trainees (Table 1). Three of the recurrences appeared in the medial border of the mesh near the pubic bone, one through too wide an external ring and one through the femoral canal.

The presence of chronic pain and the patients’ assessment of the

Discussion

Inguinal hernias are so common in the population that centralisation into specific hernia centres in Europe has not been carried out. In United States, the results of such specialist clinics have been encouraging. For example, recurrences between 0 and 1% and infections between 0 and 5% have been reported [8], [11], [12]. The results of nonspecialist hospitals have been slightly worse reporting recurrence rates between 4 and 7% [3], [13], [14]. Our results indicate that the open tension-free

References (20)

There are more references available in the full text version of this article.
View full text
Copyright © 2003 Elsevier B.V. All rights reserved.