Influence de la formation chirurgicale et de l'apprentissage sur les résultats du traitement laparoscopique des hernies de l'aine

Abstract

Study aim

The aim of this retrospective study was to compare two concurrent series of patients operated on for inguinal hernia with the same laparoscopic procedure, the first one in a teaching hospital with a number of trained surgeons and the second one in a private center with only one trained surgeon.

Patients and method

Five hundred and forty-one patients with 757 hernias were operated on over a period of six years by a totally pre-peritoneal laparoscopic approach. Two hundred and sixteen patients were operated on in a teaching hospital by 48 surgeons (six senior and 42 trainee surgeons; group I), 325 were operated on in a private center by one surgeon who had been trained in the same teaching hospital (group II). The two groups of patients and their hernias were comparable. The comparison was established on the following criteria: duration of operation, rate of conversion, length of hospitalization, morbidity and mortality rate, recurrence rate and costs.

Results

Operations performed by surgical trainees were associated with: (1) a mean operative time significantly (P = 0.01) longer for both unilateral (68 vs. 41 min) and bilateral (108 vs. 68 min) hernias. The operative time did not change in the teaching hospital and decreased with experience in private practice (from 62 to 25 min for unilateral hernias); (2) more frequent per-operative complications, particularly opening of the peritoneum (28% vs. 3%, P = 0.001); (3) a mean duration of hospitalization significantly (P = 0.05) longer, on average by 1.6 d; (4) a morbidity rate after 30 days significantly higher (16.2% vs. 4.9%, P = 0.01); and, (5) higher costs. There was no significant difference concerning mortality rate (nil), conversion rate (1.5%) and recurrence rate (1.3% vs. 0.6%, non significant).

Conclusion

Surgical training for laparoscopic treatment of inguinal hernias was associated with a longer operation time and hospital stay, and with higher morbidity and costs. After a good initial training in a teaching hospital, surgeons were capable of performing laparoscopic repair of inguinal hernias with good results.