The Coming of Age of Complex Laparoscopy in a Community Teaching Hospital: Practice Patterns Learned From a Laparoscpic Ventral Hernia Repair Model

Ashwin A Kurian, MD, Sidhbh Gallagher, MD, Robert Josloff, MD. Abington Memorial Hospital

Objective: Assess practice patterns in the incorporation of complex laparoscopy by general surgeons in a community teaching hospital using a laparoscopic ventral hernia repair (LVHR) model.
Methods: Univariate and multivariate regression analysis of patient and intraoperative variables was conducted on a prospectively acquired database of LVHRs performed between April 2001 to July 2010. Patients were divided into, Group 1 (patients operated on by seven surgeons without advanced laparoscopic fellowship training) and Group 2 (patients operated on by three surgeons trained in advanced laparoscopic fellowships). A multivariate logistic regression model was created, to determine independent variables that correlate with length of procedure, (LOP: surrogate for the incorporation of advanced laparoscopic skills in the surgeons practice). P value <0.05 was considered significant.
Results:
Descriptive Analysis: 324 patients underwent elective LVHR with a mean age of 56.6 years. There were 230 patients in Group 1, and 94 patients in Group 2. The average BMI was 32.5 (range: 17 – 64). The overall conversion rate to open operation was 4.9%. The mean LOP was 96 minutes (range: 28 -418 minutes).
Univariate Analysis: The mean age was significantly higher in Group 2 (55 vs 59 years, p=0.03). There were a higher percentage of females (45% vs 67%, p=0.0006) and patients with incisional hernias (48% vs 76%, p=0.0001) in Group 2. The mean BMI and ASA grade distribution was not statistically dissimilar between the two groups. There was a significantly higher percentage of patients with recurrent hernias (19% vs 27%, p = 0.042) and complex hernias (21% vs 31%, p = 0.003) in Group 2. The mean size of mesh used in the repair (surrogate for hernia size) was significantly higher in Group 2 (175 vs 230 cm², p = 0.008), as was the mean number of trans-fascial sutures used (2.3 vs 4.5 sutures, p < 0.0001). The mean length of procedure was significantly longer in Group 2 (90 vs 112 minutes, p = 0.0008).
Logistic Regression: A multivariaite logistic regression model was created with LOP being the dependent variable. Five factors were independently associated with a significant longer LOP on mutivariate logistic regression analysis (p<0.05): mesh size (p<0.0001), complex hernias (p=0.0002), incisional hernia (p=0.0003), lysis of adhesions (p=0.001) and patient age (p=0.02). Significantly, an advanced laparoscopic fellowship was not independently associated with LOP.

Conclusions: Practice patterns suggest incorporation of laparoscopic techniques in the management of ventral hernias among general surgeons. Surgeons with advanced laparoscopic training tend to operate on larger and more complicated ventral hernias. Advanced laparoscopic training does not significantly decrease the length of this particular procedure, suggesting that general surgeons have incorporated the skills required to approach the laparoscopic management of ventral hernias into their skill set. Mesh size, complex hernias, incisional hernias, need for lysis of adhesions and patient age independently predict a longer length of procedure when a patient undergoes a laparoscopic ventral hernia repair.