Edited by: Juan A. Tovar, Hospital Universitario La Paz, Spain
Reviewed by: Dariusz Patkowski, Wroclaw Medical University, Poland; Manuel Lopez, Hospital Universitari Vall d’Hebron, Spain; Go Miyano, Juntendo University, Japan
Specialty section: This article was submitted to Pediatric Surgery, a section of the journal Frontiers in Pediatrics
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We analyzed the department and surgeon learning curves during implementation of the percutaneous internal ring suturing (PIRS) technique in our department.
Children proposed for inguinal hernia or communicating hydrocele repair were included (
Department-centered analysis revealed that perioperative complications, conversion, and ipsilateral recurrence rates were higher in the beginning, reaching the benchmarks when each surgeon performed, at least, 35 laparoscopic repairs. Postoperative complications and metachronous hernia rates were independent from learning curves, with the metachronous hernia rate being significantly lower in PIRS patients. During the program, the percentage of males in those operated by PIRS progressively increased reaching the percentage of males, in our sample, when department operated over 230 cases.
Thirty-five laparoscopic cases per surgeon are required for perioperative complications, conversion, and ipsilateral recurrence reach the benchmark. The gap between the percentage of males, in those operated by PIRS and in those proposed for surgery, monitors the confidence of the team in the program.
For years and years, infants and children with surgical indication for repairing inguinal hernia or communicating hydrocele were treated with high ligation and division of the sac by an open inguinal approach. Around the 1990s, after the first report of a laparoscopic inguinal hernia repair (
A few years ago, our department decided to implement a minimally invasive program to repair inguinal hernia and communicating hydrocele embroiling all staff members. After a systematic review and mentorship, the percutaneous internal ring suturing (PIRS) technique (
Herein, we evaluate our department- and surgeon-centered learning curves trying to extract some lessons we can share with other centers implementing a similar program.
This study was approved by the scientific ethic committee from our institution with the reference: SECVS 133/2014. All staff members involved in the program were consultants with basic training as pediatric surgeons and different skill levels in laparoscopic surgery. We included all children submitted to surgical repair of indirect inguinal hernia (at any age) or communicating hydrocele (older than 2 years old) since June 2011 until November 2016 in our department. The patients were either operated by open approach (OA group) or by percutaneous internal ring suturing (PIRS group). The decision of proposing the minimally invasive approach was surgeon-dependent, and determined by each surgeon’s experience, beliefs, and confidence on the technique. Patients with hernias other than indirect inguinal hernia were excluded.
Demographic data and clinical details were gathered, including gender, age, diagnosis (hernia vs. communicating hydrocele), pre- vs. perioperative laterality match, identification of silent patent
Femoral vein puncture, a perioperative complication. The procedure was interrupted, and the bleeding was controlled with external compression.
Inguinal foreign-body reaction, a postoperative complication emerging 4 weeks after surgery.
Both techniques were performed under general anesthesia (laryngeal mask) with the patient lying in a supine position.
For open repair, we used a classic technique that divides the sac and closes the peritoneum at the level of the internal inguinal ring after opening the skin, Scarpa’s fascia, and the aponeurosis of the external oblique muscle.
The procedures were performed under general anesthesia (laryngeal mask) with the patient lying in a supine position. The surgeon stood at the right side of the patient regardless of the affected side, and the monitor was placed at the bottom of the table. Our minimally invasive approach included the ligation of the
Global data regarding both OA and PIRS groups were analyzed and compared when appropriate. To assess the success of implementation of the minimally invasive program for repairing inguinal hernia and communicating hydrocele, the learning curves were studied in two different ways: through a department- and a surgeon-centered analysis. The intervention on each patient was always considered a single procedure independently of being unilateral and bilateral repairs.
In the department-centered analysis, the OA group was used to set the benchmarks of the department. PIRS group was divided in chronological sequential tertiles (PIRS 1st–114th; PIRS 115th–228th; PIRS 229th–341st). The following rates were calculated for each tertile: i. perioperative complications (%); ii. postoperative complications (%); iii. ipsilateral recurrence (%); iv. conversion to open repair (%); and v. males benefiting from PIRS (%). The first three rates aimed to assess either the efficacy of the technique and the expertise of the surgical team. The other two rates mainly assessed the belief of the surgical team on the benefits of the procedure and their own self-confidence in performing the technique. The tertiles were compared with each others and with the benchmark (when appropriate).
In the surgeon-centered analysis, the staff surgeons who adopted PIRS as the technique of choice were selected, in order to achieve individual sequential case series. For each surgery serial number, we calculated the rate of perioperative complications, ipsilateral recurrence, and conversion to open surgery. The results were displayed in a surgeon’s cumulative experience chart. A visual analysis was performed based on the events decline to determine the serial number of cases required to complete the learning curve.
Data analysis was performed using SPSS software version 24.0 (SPSS, Chicago, IL, USA). Chi-square test was used to compare the distribution of categorical variables between groups. Statistical significance was defined as a two-sided
Six hundred seven cases matched the inclusion criteria and were included in this study (Table
Demographic characteristics and clinical outcomes of the open approach (OA) and percutaneous internal ring suturing (PIRS) groups.
Open group ( |
PIRS group ( |
||
---|---|---|---|
Male gender, no. (%) | 228 (86%) | 216 (63%) | |
Age, mean (SD), years | 3.8 ± 3.5 | 4.2 ± 3.4 | |
Diagnosis, no. (%) | |||
Hernia | 164 (62%) | 311 (91%) | |
Hydrocele | 102 (38%) | 30 (9%) | |
Silent patent |
– | 58 (17%) | |
Mismatch with preoperative laterality, no. (%) | – | 15 (4.4%) | |
Conversion, no. (%) | – | 3 (0.9%) | |
Reported perioperative complications, no. (%) | 1 (0.4%) | 8 (2.3%) | 0.085 |
Postoperative complications, no. (%) | 6 (2.3%) | 9 (2.6%) | 0.799 |
Ipsilateral recurrence, no. (%) | 1 (0.4%) | 5 (1.5%) | 0.238 |
Metachronous recurrence, no. (%) | 14 (5.3%) | 1 (0.3%) | <0.001 |
In the department-centered analysis, perioperative complications rate was significantly greater than the benchmark in the first and third tertiles (Figure
Department-centered analysis of the learning curve of percutaneous internal ring suturing (PIRS) technique considering
Confidence of the surgical team on the technique reflected by
Out of six surgeons beginning the program only five adopted PIRS as the technique of choice. Each of these performed a minimum of 50 surgeries. The results chart (Figure
Surgeon-centered analysis of the learning curve of percutaneous internal ring suturing (PIRS) technique. The graph reflects the cumulative experience of five staff surgeons throughout their first 50 surgeries by PIRS. The performance was evaluated by the
This study assessed the evolution of the department and surgeon’s learning curves during a minimally invasive program to repair inguinal hernia and communicating hydrocele in children. The program was presented 5 years ago to our staff surgeons (all with different experience in minimally invasive procedures) and the proposed benchmarks were leastwise the results we had in the classical open repair. The selected minimally invasive technique was the PIRS (
In the department-centered learning curve analysis, five of the six staff members adhered to the program. However, there was a disparity on the implementation cadence by each of them. Therefore, we also performed a surgeon-centered learning curve analysis.
The cosmesis was excellent with our strategy to insert the optics and dissecting 3-mm instrument through the umbilicus. In fact, there were no visible scars at the end of the procedure. In the department analysis, perioperative complications and ipsilateral recurrence rates showed some undulant pattern, despite the downward trend along the tertiles. The underlying explanation might be the surgeons’ cadence disparity when starting their learning process, as each surgeon’s accumulated experience contributing to each tertile was not the same. When analyzing the surgeon-centered learning curves, we perceived a more consistent decline in perioperative complications and ipsilateral recurrence with experience. In contrast to perioperative complications, ipsilateral recurrence, and conversion rates, the postoperative complications rate was consistently similar along all tertiles (PIRS group) and the benchmark (OA group). We concluded that postoperative complications are not dependent on the learning curve, but on the technique
In the literature, PIRS technique had been associated with higher rates of ipsilateral recurrence and residual hydroceles (
The laparoscopic approach allows the identification of contralateral patency of the
Finally, a deep analysis of our data suggested that the main reasons generating some distress among surgeons for proposing a minimally invasive approach in the beginning of the program were the male gender and the youngest ages of infants. In fact, we could verify that the percentage of males with inguinal hernia or communicating hydroceles proposed for minimally invasive repair increased along the tertiles and reached the benchmark (percentage of males with inguinal hernia or communicating hydroceles in our population) only at third tertile. At the beginning of the program, surgeons selected female patients to start with as their anatomy appears more favorable (
In conclusion, our study demonstrates that independently of previous surgical experience in minimally invasive surgery, pediatric surgeons easily adhere to the implementation of a minimally invasive program to repair inguinal hernia and communicating hydrocele. In contrast to postoperative complications, which were technique and experience independent, there was a learning curve for perioperative complications, ipsilateral recurrence, and conversion rates that reached the nadir after each surgeon performed at least 35 cases. After this, the laparoscopic repair is a safe and effective approach, whereas the cosmesis and the virtual extinction of metachronous contralateral hernia were the major advantages. The gap between the percentage of males in those proposed for surgical repair and the percentage of males in patients operated by PIRS can be used as an index to monitor the confidence of the surgical teams that decide to adopt a similar program to repair inguinal hernia and communicating hydrocele by minimally invasive surgery.
This study was carried out in accordance with the recommendations of the Declaration of Helsinki with written informed consent from all subjects. The protocol was approved by the scientific ethic committee from our institution.
The study conception was performed by CB, RL-P, and JC-P, data acquisition by CB, PE, AA, and JC. For interpretation of data and analysis, CB, AO, RL-P, and JC-P were involved. The manuscript was written by CB and JC-P and revised by JC, RL-P, and JC-P.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The Supplementary Material for this article can be found online at
Percutaneous internal ring suturing leaving no peritoneal gaps.