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Rapid Hernia Repair Increases Likelihood of ReoperationOctober 19, 2011 — The assumption that surgical efficiency always leads to superior clinical outcomes has been challenged by a Swedish study that correlates fast operation times for hernia repairs with an elevated risk for repeat surgeries. The study was published in the October issue of the Archives of Surgery.
On the basis of 123,917 primary groin hernia repairs covered in the Swedish Hernia Repair Registry between 1998 and 2007, Willem van der Linden, MD, PhD, and colleagues from Östersund Hospital in Sweden found far different safety profiles for rupture repairs completed in less than 36 minutes and those completed in more than 66 minutes. The risk for recurrence from hernia repairs performed in under 36 minutes was 26% higher than that in repairs performed in over 66 minutes (relative risk [RR], 1.26; 95% confidence interval [CI], 1.11 - 1.43).
Dr. van der Linden and colleagues found, on the other hand, that the risk for postoperative complications increased with longer operations times. Although deep infections were rare, the incidence of infections and complications, such as hematoma and urinary retention, was higher for surgeries taking more than an hour.
The common perception that speed in the operating room improves outcome is related to a belief that faster surgeons are more skilled and experienced; a surgeon’s speed, the researchers note, should be reflected in volume. In the current study, surgeons who performed a larger volume of groin hernia repairs tended to complete the procedures more quickly than surgeons who performed fewer hernia operations.
Surgeons who performed more than 50 hernia repairs annually completed 8 times as many procedures in less than 36 minutes than procedures taking more than 66 minutes. Surgeons who performed 5 or fewer repairs annually completed 3 times more operations in more than 66 minutes than procedures finished in less than 36 minutes.
Yet slower surgical times actually appeared to protect patients against the risk for repeat surgeries. The researchers identified a 1.7% reoperation rate for patients whose procedures took more than 66 minutes. Their outcomes were significantly better than those of patients who were in and out of the surgical suite in less than 36 minutes. Their resurgery rate was 2.8% (P < .001).
Results indicated that plug and laparoscopic methods were performed faster than other methods. The Lichtenstein method of groin hernia repair, which has become the standard in Sweden, was more time-consuming than other techniques; but, interestingly, even more repeat surgeries were required when this approach was completed quickly, with an increased RR of 45% (1.45; 95% CI, 1.21 - 1.75) for Lichtenstein procedures performed under 36 minutes compared with those taking longer than 66 minutes.
The main study limitation is the use of reoperation as the endpoint rather than recurrence because the latter cannot be measured from registry data.
Dr. van der Linden and colleagues suggest that the reason that fast hernia repairs lead to relatively more repeat surgeries is the nature of the operation itself. Compared with most complex surgeries, the indications of threatened technical failure are not easy to recognize during rupture repair.
"In hernia surgery, therefore, careful, time-consuming repair may pay off," they write.
To date, "[t]he general impression seems to be that speed reflects skill, which in turn stems from experience gained by large volume, whereas prolonged operations are assumed to signify inexperience or trouble," write the study authors. "By contrast, in the present series, the presumed skill gained by volume manifested itself in speed but did not show up in outcome."
In an accompanying editorial, surgeons Matthew J. Carthy, MD, and Stanley W. Ashley, both from Brigham and Women’s Hospital, Boston, Massachusetts, praised the study for revealing a poorly appreciated paradox between clinical efficiency and effectiveness.
"By providing further insight into the dynamics at the fringes of efficiency and safety, van der Linden and colleagues advance our understanding regarding the limits to which performance improvement efforts can be taken and, therefore, enhance our notions of how such efforts can achieve maximal health care value," they write.
Jacqueline A. Hart, MD, contributed to this article.
The study was supported by the County Council of Jamtland. The Swedish Health Registry is supported by the Swedish Association of Local Authorities and the National Board of Health and Welfare. The study authors and the editorialists have disclosed no relevant financial relationships.
Arch Surg. 2011;146:1198-1203. Abstract
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