Effect of subspecialty training and volume on outcome after pediatric inguinal hernia repair

Presented at the 35th Annual Meeting of the American Pediatric Surgical Association, Ponte Vedra, Florida, May 27-30, 2004. Supported by the Robert M. Filler Chair in Pediatric General Surgery, Hospital for Sick Children Research Institute, the Canadian Institutes of Health Research, and the Ontario Ministry of Health and Long-term Care.
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Abstract

Background/Purpose

Inguinal hernia repair is the most common operation performed in children. The aim of this study was to determine if there are any differences in outcome when this procedure is performed by subspecialist pediatric surgeons when compared with general surgeons.

Methods

All pediatric inguinal hernias repaired in the province of Ontario between 1993 and 2000 were reviewed using a population-based database. Children with complex medical conditions or prematurity were excluded. Cases done by general surgeons were compared with those done by pediatric surgeons. The χ2 test was used for nominal data and the Student's t test was used for continuous variables. Probabilities were calculated based on a logistic regression model.

Results

Of 20,545 eligible hernia repairs, 50.3% were performed by pediatric surgeons and 49.7% were performed by general surgeons. Pediatric surgeons operated on 62.4% of children younger than 2 years, 51.8% of children aged 26 years, and 37% of children older than 7 years. Duration of operation, length of hospital stay, and incidence of early postoperative complications were similar among pediatric and general surgeons. The rate of recurrent inguinal hernia was higher in the general surgeon group compared with pediatric surgeons (1.10% vs 0.45%, P < .001). Among pediatric surgeons, the estimated risk of hernia recurrence was independent of surgical volume. There was a significant inverse correlation between surgeon volume and recurrence risk among general surgeons, with the highest volume general surgeons achieving recurrence rates similar to pediatric surgeons.

Conclusions

Pediatric surgeons have a lower rate of recurrence after inguinal hernia repair in children. General surgeons with high volumes have similar outcomes to pediatric surgeons.

Section snippets

Methods

This study used population-based data to measure trends and outcomes associated with hernia repairs in children aged 18 years or younger. The study was approved by the Research Ethics Board at the Hospital for Sick Children in Toronto.

Results

There were 20,545 hernia repairs in children younger than 19 years in fiscal years 1993 to 2000. Of these, 16,891 (82.2%) hernia repairs were performed in boys and 3654 (17.8%) in girls. Children operated on by each surgeon group were similar in sex. Pediatric surgeons performed 50.3% and general surgeons performed 49.7 % of the hernia repairs. Children younger than 1 year were more likely to be operated on by a pediatric surgeon (62.4% vs 3 7.6%, Fig. 1) whereas older children (those aged 7-18

Discussion

Several studies have shown that subspecialty training results in superior outcomes after surgical procedures. Among patients with gynecologic [6], [7] or colorectal [8], [9] cancer, outcomes were better in those patients cared for by surgeons with subspecialty training. Similarly, a number of studies suggest that children with pyloric stenosis [10], [11] or appendicitis [12], [13] have better outcomes when cared for by pediatric surgeons rather than general surgeons, although there are other

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