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Increasing volume but declining resident autonomy in laparoscopic inguinal hernia repair: an inverse relationship

  • 2022 SAGES Oral
  • Published:
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Abstract

Introduction

With improved technology and technique, laparoscopic inguinal hernia repair (LIHR) has become a valid option for repairing both initial and recurrent inguinal hernia. Surgical residents must learn both techniques to prepare for future practice. We examined resident operative autonomy between LIHR and open inguinal hernia repair (OIHR) across the Veterans Affairs (VA) system.

Methods

Utilizing the VA Surgical Quality Improvement Program database, we examined inguinal hernia repairs based on the principal procedure code at all teaching VA hospitals from July 2004 to September 2019. All VA cases are coded for level of supervision at the time of surgery: attending primary surgeon (AP); attending scrubbed but resident is a primary surgeon (AR), and resident primary with attending supervising but not scrubbed (RP). Primary outcomes were the proportion of LIHR versus OIHR and resident autonomy over time.

Results

A total of 127,497 hernia repair cases were examined (106,892 OIHR and 20,605 LIHR). There was a higher proportion of RP (8.7% vs 2.2%) and lower proportion of AP (23.9% vs 28.4%) within OIHR compared to LIHR (p < 0.001). The overall proportion of LIHR repairs increased from 9 to 28% (p < 0.001). RP cases decreased for LIHR from 9 to 1% and for OIHR from 17 to 4%, while AP cases increased for LIHR from 16 to 42% and for OIHR from 18 to 30% (all p < 0.001). For RP cases, mortality (0 vs 0.2%, p > 0.99) and complication rates (1.1% vs. 1.7%, p = 0.35) were no different.

Conclusions

LIHR at VA hospitals has tripled over the past 15 years, now compromising nearly one-third of all inguinal hernia repairs; the majority are initial hernias. Despite this increase, resident autonomy in LIHR cases declined alarmingly. The results demonstrate an urgent need to integrate enhanced minimally invasive training into a general surgery curriculum to prepare residents for future independent practice.

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Authors and Affiliations

  1. Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US

    Alvand J. Sehat, Joseph B. Oliver, Yasong Yu, Anastasia Kunac & Devashish J. Anjaria

  2. Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US

    Joseph B. Oliver, Yasong Yu, Anastasia Kunac & Devashish J. Anjaria

Authors
  1. Alvand J. Sehat
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  2. Joseph B. Oliver
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  3. Yasong Yu
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  4. Anastasia Kunac
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  5. Devashish J. Anjaria
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Contributions

AJS wrote the manuscript, contributed to study conception and design, analyzed and interpreted results, and drafted manuscript preparation. YY contributed to the study concept and design and reviewed the manuscript. AK contributed to the study image and design, analyzed, interpreted results, and reviewed the manuscript. JO contributed to study conception and design, collected, analyzed, interpreted results, and reviewed the manuscript. DA devised the main conceptual ideas for the project, analyzed and interpreted results, and reviewed the manuscript. All authors reviewed the results and approved the final version of the manuscript.

Corresponding author

Correspondence to Devashish J. Anjaria.

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Disclosures

Drs. Sehat, Yu, Kunac, Oliver, and Anjaria have no conflicts of interest or financial ties to disclose.

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Sehat, A.J., Oliver, J.B., Yu, Y. et al. Increasing volume but declining resident autonomy in laparoscopic inguinal hernia repair: an inverse relationship. Surg Endosc 37, 3119–3126 (2023). https://doi.org/10.1007/s00464-022-09476-4

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  • DOI: https://doi.org/10.1007/s00464-022-09476-4

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