5. Proficiency Of Surgeons In Laparoscopic Hernia Repair: Effect Of Age and Experience
Leigh A. Neumayer, MD*1, Atul A. Gawande, MD, MPH* 2, Jia Wang, MS* 3, Anita Giobbie-Hurder, MS* 3, Kamal MF Itani, MD*4, Robert J. Fitzgibbons, Jr., MD5, Olga Jonasson, MD6
1 VA Salt Lake City Health Care System and University of Utah Health Sciences Center, Salt Lake City, UT; 2Harvard Medical School and Harvard School of Public Health, Boston, MA; 3Hines VA Cooperative Studies Program Coordinating Center, Hines, IL; 4VA Boston Health Care System and Boston University, Boston, MA; 5Creighton University, Omaha, NE; 6University of Illinois, Chicago, IL
Objectives: In a multicenter randomized trial comparing open and laparoscopic herniorraphies, conducted in Veterans Administration Hospitals (CSP 456), we reported significant differences in recurrence rates (RR) due to surgeon experience (laparoscopic). Here we examine additional factors that might influence RR and operation time as measures of proficiency.
Methods: We analyzed data from unilateral laparoscopic herniorrhaphies from CSP 456 (n=814). Surgeon experience (experienced > 250 procedures; inexperienced <250), age, PGY of resident, operation time, and hospital observed to expected (O/E) ratios for mortality were potential independent predictors for RR and operation time. Age was dichotomized into older (> 55 years, median 59) and younger (<55 years, median 44). Factors with p<0.2 on univariate analysis were included in regression analyses.
Results: Surgeon inexperience and older age were significant predictors for recurrence while inexperience and increased O/E were significant for longer operation time. The odds for recurrence for an inexperienced surgeon are 3.2 times higher than an experienced surgeon; an older surgeon’s odds for recurrence are 2.2 times that of a younger surgeon. There is a significant interaction between experience and O/E for operation time; experienced surgeons at a high O/E hospital had longer operation times.
Conclusion: In addition to experience, this analysis demonstrates that age greater than 55 is an independent predictor of recurrence. Experience and O/E were significant predictors of operation time.
| Outcome | Predictor | Interaction | AOR | 95% CI | p-value |
| Recurrence | Inexperienced vs. Experienced | N/A | 3.19 | 1.53 - 9.49 | 0/0021 |
| Recurrence | Older vs. Younger | N/A | 2.22 | 1.14 - 4.30 | 0.0190 |
| Outcome | Predictor | Interaction | Estimate | 95% CI | p-value |
| Operation Time | Experienced vs. Inexperienced | N/A | -0.27 | -0.35 - -0.18 | <0.0001 |
| Operation Time | O/E (one unit increase) | N/A | 0.11 | 0.02 - 0.21 | 0.0162 |
| Operation Time | N/A | Experienced AND one unit increase in O/E | 0.28 | 0.10 - 0.46 | 0.0025 |
| Operation Time | N/A | Inexperienced AND one unit increase in O/E | 0.05 | -0.06 - 0.16 | 0.3722 |