Does Resident Post Graduate Year Influence the Outcomes of Inguinal Hernia Repair?

To the Editor:

A well-planned research study usually produces many valid questions; accordingly, the work of Dr. Wilkiemeyer et al¹ is to be commended as it documents two significant problems in the performance of inguinal herniorrhaphy by surgical residents: 1) post graduate year (PGY) 1 and PGY2 produced a disturbingly high recurrence rate; and 2) the rate took place even when assisted by board-certified general surgeons, raising questions about both present surgical resident training and attending supervision. In this study, PGY1 and PGY2 were responsible for a 3-year recurrence rate of 7% and 5.2%, respectively. Extrapolated to our national number of yearly herniorrhaphies, which is about 800,000, that performance would yield approximately 56,000 and 41,600 yearly recurrences, respectively, an unacceptably high failure rate.

Inguinal herniorrhaphy is an ideal operation to teach because the regional anatomy has been well described and the repair techniques are well outlined and reproducible. However, it requires a solid knowledge of the necessary steps to first dissect the structures and then complete the repair.

The reality is that the initiate resident comes to the OR with virtually no surgical manual skills and during the first months of training and during those critical first procedures he or she has to learn the basic gestures of incising, dissecting, hemostatic clamping, and suturing tissues. Throughout those months, the resident has to concentrate on learning his handicraft and has virtually no opportunity to master the required repair steps; hence, the high recurrence rate and the lengthy operations. The failure rate declines as their advanced training validates this thesis. This probably happened when the resident's manual skills become automatic and the resident was able to concentrate on the repair itself.

Intensive, supervisor-rated practicing in an animal or dummy setting, the basic surgical handicraft motions of incising, dissecting, clamping, tying, and suturing may permit PGY1 to approach a patient in need of a herniorrhaphy without having to learn those basic skills during the procedure, allowing them to concentrate on the mechanics of the repair. This approach may accelerate resident training and reduce many tense and frustrating OR occurrences.

The fact that direct attendance by board-certified general surgeons did not prevent the initial substandard performance opens another set of questions about the benefit of such supervision if the trainee's manual skills are yet to be developed.

Maximo Deysine, MD
Department of Surgery
Winthrop University Hospital
Mineola, NY
maxdey@optonline.net