Teaching and learning of laparoendoscopic hernia surgery in India: A challenge – problems and solutions

Abstract

INTRODUCTION: One German surgeon (Eric Mühe in 1985)* and three French surgeons** (Philippe Mouret in 1987, Jacque Perissat in 1989, and Dubois F in 1990) are credited with having performed first* laparoscopic cholecystectomy and first** video-assisted laparoscopic cholecystectomy, respectively. Laparoscopic cholecystectomy became the procedure of choice (gold standard) for benign symptomatic gallbladder disease as well as asymptomatic gallbladder stones in India. There have been adoption and acceptance for laparoendoscopic incisional/ventral hernia repair. Actually, laparoendoscopic repair of incisional/ventral hernia, laparoscopic solid organ removal (spleen and adrenal), and laparoscopic fundoplication (gold standard) have been standard of care even in the absence of Level 1 evidence over the past three decades. AIM: However, acceptance, adoption, adaptation, and performance of laparoendoscopic groin hernia surgery have been slow over the past three decades among practicing surgeons and surgical trainees. RESULTS: The laparoendoscopic groin hernia repair has yet not gained the same status as for the procedures mentioned above (VS). The reasons are multifactorial and relate to obtaining adequate and proper training covering laparoendoscopic groin hernia repair. The first and foremost reason is that endoscopic repair of groin hernia is considered an advanced laparoscopic procedure as opposed to open hernia repair. Preceptorship–proctorship (PP) model, which worked extremely effectively for teaching and learning of laparoscopic cholecystectomy, could not be established for groin hernia yet. There is no effective simulator developed for any of the standardized techniques, i.e., totally extraperitoneal (TEP) and/or transabdominal preperitoneal repair (TAPP). The complications, for example, intestinal obstruction and major vascular injury, which were never seen during open era, also brought about criticism as well hampered the growth of laparoendoscopic groin hernia repair. In emerging economies such as India and other Asian countries, high cost of laparoendoscopic repair (tacker and specialized meshes) has been responsible for reduced penetration among practicing surgeons and patients. Therefore, the laparoendoscopic repair of groin hernia has been limited to major metropolitan corporate hospitals and small number of tertiary care public hospitals in metropolitan cities. The advantages of minimally invasive approaches for the repair of groin hernias have not benefited the masses in rural and semi-urban geographic areas of India. CONCLUSION: Training opportunities for the teaching and learning laparoendoscopic repair of groin hernia have remained limited for vast majority of practicing surgeons and surgical trainees in India. With development of cadaveric (TEP and TAPP) and live anesthetized animal model (TAPP), it has been possible to establish training opportunities for practicing surgeons at few institutions. We also recommend and encourage expert surgeons to provide training opportunities for those who wish to learn the surgical skills of laparoendoscopic repair of groin hernia by giving their time for PP model. Furthermore, establishment of specialized hernia centers will go a long way to fill this void.

Keywords

• cadaveric model of hernia training
• endoscopic hernia repair
• laparoscopic cholecystectomy
• ipom
• laparoscopic hernia repair
• tapp
• tep