Operative Time Is an Effective Tool to Evaluate Intraoperative Performance for Procedure-specific Tasks in Totally Extraperitoneal Herniorrhaphy (TEP)

Tung T Tran, MD, MSc, Vinay Singhal, MD, Ryan Juza, MD, Eric Pauli, MD, Ann Rogers, MD, Randy Haluck, MD, Jerome Lyn-Sue, MD

Penn State Milton S. Hershey Medical Center

INTRODUCTION: The widespread adoption of totally extraperitoneal herniorrhaphy (TEP) has created challenges in the evaluation and training of surgeons. The development of assessment tools for procedure-specific tasks is of paramount importance for complex minimally invasive procedure such as TEP. Mesh positioning and securement are standard tasks in TEP. The objective of our study was to validate operative time for a procedure-specific task (mesh placement) as a tool to assess intraoperative performance that could potentially lead to the development of a learning curve for this procedure.

METHODS: Participants were assessed in the operating room. Performance was assessed using operative time from the time of mesh introduction until satisfactory mesh and tack placement. Demographic data were recorded. Surgeon experience was recorded using ABS case logs. Longitudinal and known groups validity was evaluated. Data are expressed in median and interquartile range[IQR]. p <.05 was considered to be significant.

RESULTS: A total of 2 experienced surgeons, 6 intermediate surgeons (MIS fellows) and 3 novices (PGY II-IV) participated in the study. At the start of the study, experienced surgeons had performed >100 cases, intermediate surgeons had a median 9.5 [6-21] cases and novices had performed 1 [1-1] case. A total of 44 procedures were performed on 43 patients. Experienced surgeons had lower operative times to complete the task (105 [90-120]sec) as compared to intermediates (240 [165-262]s) who had significantly lower operative times than novices (600 [600-600])s) (p<0.01) at the start of the study. These results were maintained throughout the study with median times of 75 [69-105]s for expert surgeons, 195 [180-240]s (p<0.01) for intermediates and 600 [520-600]s (p<0.01) for novices. In our study, MIS fellows had a median of 5 [2-9] trials. These intermediate surgeons showed an improvement in operative times with increasing trials. Among fellows, experience of greater than 10 cases was associated with shorter operative times (180vs343s) (p<0.01). The number of cases performed correlated with improved times. (r= -0.8) (p<0.01).

CONCLUSION: Operative time for a procedure-specific task (mesh placement in TEP) can be used to evaluate intraoperative performance and is potentially valuable in determining the learning curve for TEP.

Session: Poster Presentation

Program Number: P161