Comparison of Early Experience and Learning Curves Associated with Minimally Invasive Hiatus Hernia Repair

Paul Del Prado, MD¹, Rachit D Shah, MD², Gretchen Aquilina, DO¹, Guilherme M Campos, MD, PhD¹, James G Bittner IV, MD¹. ²Virginia Commonwealth University, Medical College of Virginia, Department of Surgery, Division of Cardiothoracic Surgery, Richmond, Virginia, ¹Virginia Commonwealth University, Medical College of Virginia, Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Richmond, Virginia

OBJECTIVES: Minimally invasive hiatus hernia (HH) repair is a complex procedure with a significant learning curve. Few publications report outcomes of surgeons trained in different specialties during their early learning curve. The study objectives are to document clinical outcomes of minimally invasive HH repair during the early learning curve and compare simultaneous learning curves across surgical specialties.

METHODS: From November 2012 to August 2015, all consecutive patients who underwent minimally invasive HH repair at a large urban university hospital by one of two fellowship-trained surgeons early in their clinical experience were included. The surgeons’ fellowship training differed by specialty (MIS-minimally invasive surgery vs. CT-thoracic and esophageal surgery). Both individuals began practice in 2012 with simultaneous learning curves. Prospectively collected data were evaluated and patients were grouped by surgeon specialty to compare outcomes and learning curves. Data are compared between surgeon type using non-parametric tests (α=0.05).

RESULTS: Ninety-three consecutive patients (MIS 46, CT 47) with mean age 59.4 years (median ASA 3) underwent laparoscopic (MIS 54%, CT 68%, P=0.2), robotic (MIS 46%, CT 28%, P=0.09), or thoracoscopic (CT 4%) HH repair. Most patients were female (67%), had types II (20%), III (42%), or IV (7%) HH, and at least one co-morbidity including hypertension (51%), obesity (47%) or hypercholesterolemia (33%). Mean operative time was 287 minutes, 51 patients underwent Nissen fundoplasty (MIS 78%, CT 32%, P<0.01), 24 had partial fundoplication (MIS 15%, CT 36%, P<0.01), 18 had no anti-reflux procedure (MIS 6%, CT 32%, P<0.01), and 14 needed gastrostomy (MIS 1%, CT 28%, P<0.01). Sixty patients (65%) received mesh reinforcement (MIS 48%, CT 26%, P=0.03) and 18 underwent thoracostomy for capnothorax (MIS 1%, CT 38%, P<0.01). Perioperative complications excluding capnothorax occurred in 17 patients (MIS 19%, CT 23 P=0.8) and included esophageal perforation (4%), esophageal stricture requiring dilation (3%), mediastinal hematoma (1%), and subphrenic abscess (1%).  Acute reoperation was necessary in 6 patients (MIS 4%, CT 8.5%, P=0.7) for perforation/leak, re-herniation, or mediastinal hematoma. Overall hernia recurrence rate was 6.5% with 3 recurrences in each cohort. The learning curves of each surgeon were statistically similar based on operative times. The trend was for operative times to increase from cases 12 to 24 as surgeons took on more complex patients and then decrease between cases 25 to 46.

CONCLUSIONS: Surgeons early in their clinical experience with distinct specialty training perform minimally invasive HH repair safely with comparable learning curves and perioperative outcomes.