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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 125-129

How to teach and learn transabdominal preperitoneal effectively – Experience with introducing transabdominal preperitoneal repair in ten general hospitals in Slovenia (2013–2018)


1 Slovenian Hernia Society, Executive Committee, Slovenian Medical Association, Ljubljana, Slovenia; Department of Surgery, Hospital of the Brothers of St. John of God, Sankt Veit an der Glan, Austria
2 Slovenian Hernia Society, Executive Committee, Slovenian Medical Association, Ljubljana; Department of Surgery, General and Teaching Hospital Izola, IzolaIsola, Slovenia
3 Slovenian Hernia Society, Executive Committee, Slovenian Medical Association; Department for General and Abdominal Surgery, University Clinical Center, Ljubljana, Slovenia
4 Slovenian Hernia Society, Executive Committee, Slovenian Medical Association, Ljubljana; Department of Surgery, General Hospital Novo Mesto, Novo Mesto, Slovenia

Date of Submission15-Jul-2019
Date of Acceptance17-Jul-2019
Date of Web Publication22-Oct-2019

Correspondence Address:
Dr. Jurij Gorjanc
Slovenian Hernia Society, Executive Committee, Slovenian Medical Association, Dunajska 162, 1000 Ljubljana

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_29_19

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  Abstract 


INTRODUCTION: Laparoscopic inguinal hernia repair, according to indications, should be offered to every patient in developed countries nowadays. However, in Slovenia, before 2013, only two hospitals (among 13) performed laparoendoscopic procedures routinely for the treatment of inguinal hernias. Besides, until 2016, the Health Insurance Institute of Slovenia (ZZZS) refunded costs according to diagnosis and not procedure and therefore did not stimulate introduction of more costly surgical procedures, such as transabdominal preperitoneal (TAPP) into daily practice. Many hospitals avoided TAPP as a nonprofitable procedure.
METHODS: In 2012, the Slovenian Hernia Society hosted Prof. Dr. Reinhard Bittner as invited guest for teaching laparoscopic and open techniques. The symposium was followed by workshops with hands-on possibility in different hospitals. Soon thereafter, many TAPP and other workshops followed in local hospitals, organized by tutors of the Slovenian Hernia Society (about five workshops a year). Official meetings between the Slovenian Hernia Society and the ZZZS were organized.
RESULTS: Between the years 2013 and 2018, ten more hospitals (one clinical center and nine general hospitals) started with TAPP procedures on a daily basis after more workshops were organized in their own local surgical department. In every hospital, one or more surgeons were delegated to take responsibility for hernia surgery development in their own department. The health insurance system agreed to raise refund for bilateral inguinal hernia repair.
CONCLUSIONS: Availability of laparoscopic inguinal hernia repair in the 3rd millennium should be a must in every EU country. TAPP was successfully introduced and consolidated as inguinal hernia repair technique in ten more hospitals across Slovenia in a relatively short period of 6 years (2013–2018).

Keywords: Inguinal hernia, learning, Slovenian Hernia Society, teaching, transabdominal preperitoneal


How to cite this article:
Gorjanc J, Jakomin T, Hubad A, Golob KB. How to teach and learn transabdominal preperitoneal effectively – Experience with introducing transabdominal preperitoneal repair in ten general hospitals in Slovenia (2013–2018). Int J Abdom Wall Hernia Surg 2019;2:125-9

How to cite this URL:
Gorjanc J, Jakomin T, Hubad A, Golob KB. How to teach and learn transabdominal preperitoneal effectively – Experience with introducing transabdominal preperitoneal repair in ten general hospitals in Slovenia (2013–2018). Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2021 Oct 19];2:125-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/4/125/269730




  Introduction Top


Laparoscopic inguinal hernia repair, according to indications, should be offered to every patient in developed countries nowadays. Besides for primary unilateral inguinal hernia, the European Hernia Society (EHS) guidelines on the treatment of inguinal hernia in adult patients recommend laparoscopic technique for inguinal hernia, especially in bilateral inguinal hernia and recurrent inguinal hernia after anterior approach.[1] Other indications are inguinal hernia in women and femoral hernias.[2] Among laparoscopic approaches for inguinal hernia, both transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) are similarly safe and effective techniques. Absolute outcome differences in comparing TAPP and TEP techniques are small. Both procedures have comparable outcomes regarding duration of operation, hematoma, length of stay, time to return to usual activity, or recurrence.[3] Some controlled trials confirmed that TAPP seems to be superior to TEP in terms of less postoperative complications, shorter operating times, and lower conversion rates.[4] In countries without previous experience of laparoscopic hernia surgery or delayed implementation of guidelines for groin hernia management, it seems more reasonable to instruct TAPP than TEP. learning curve in TAPP is shorter than in TEP; transabdominal approach is more familiar for general surgeons than preperitoneal approach, possibly lower costs for TAPP.[5] Last but not least, in incarcerated inguinal hernia, which is a common diagnosis in many emergency centers of general hospitals, laparoscopic bowel check and subsequent TAPP is a more convenient option.[6],[7]

Reasons for delayed implementation of laparoscopic techniques in hernia surgery in Slovenia are not just professional (medical technical), although learning takes time and dedication; they also have an economical and budgetary background. Slovenia is one of the three most developed postcommunist countries of Central and Eastern Europe. The country is a full EU member since 2004 and has introduced Euro as currency since 2007. Its health-care system is similar to other postcommunist countries – it is financed according to patterns that are nowadays more and more understood as the historical burden of the past.[8] While in Eastern Europe and Central Asia the budgetary financing prevails, Central Europe is dominated by funding with health insurance contributions. The problem of the former Eastern Bloc countries, including Slovenia, is the low monetary amounts that may be used to finance health-care services, medications, rehabilitation, or additional services.[9] The costs of medical equipment and medicines are similar in all countries around the world, and in many of the (slightly) underdeveloped ones, only basic treatments and therapies are financed.[10] Thus, in many countries of the former Eastern Bloc, there are still some difficulties in access to modern medical technologies.[11]

Besides, the Health Insurance Institute of Slovenia (ZZZS) refunds costs according to diagnosis and not according to the procedure.[12] Therefore, the health insurance system does not stimulate the introduction of more costly surgical procedures, such as TAPP into daily practice. Many hospitals avoided TAPP in the past as a nonprofitable procedure. Besides that, the motivation for introducing a technique without support from expert committees in the hospitals or nationwide was low among surgeons. Because of that, the Slovenian Hernia Society made a decision to start promoting TAPP in a constructive and supportive way in 2012.


  Methods Top


In Slovenia, before 2012, just two of 13 hospitals performed laparoendoscopic procedures for the treatment of inguinal hernias, both for selected cases only. TAPP was performed in one hospital and TEP in another.[13],[14] The first TAPP procedure in Slovenia was introduced in 1994.[13]

In order to promote minimally invasive hernia surgery, the Slovenian Hernia Society (www.hernia.si) organized symposium and workshop on laparoscopic inguinal hernia repair (TAPP) with Prof. Dr. Reinhard Bittner as an invited guest in Ljubljana University Clinical Centre in 2012. Representatives from 2 clinical centers and from all 11 regional hospitals attended. In the following years (2013–2018), many TAPP and other workshops followed in the regional hospitals, organized by proctors of the Slovenian Hernia Society (3–5 local hospital workshops a year). Surgeons with experiences of >200 TAPP procedures were leading workshops and mentored local expert meetings, including surgical assistance to local surgeons in the operating theater. In addition, official meetings between the Slovenian Hernia Society and the ZZZS were organized in order to bring refunding for TAPP to a higher level.

The number of performed laparoscopic inguinal hernia operations was analyzed in the period 2013–2018 and compared with all inguinal hernia repairs in the same period. Data on operative procedures were obtained officially from the ZZZS.


  Results Top


Between the years 2013 and 2018, ten more hospitals (one clinical center and nine general hospitals) started with TAPP procedures on a daily basis after more workshops were organized in their own local surgical department [Figure 1]. In every hospital, one or more surgeons were delegated to take responsibility for hernia surgery development in their own department. They are in close contacts with the Slovenian Hernia Society and offer them feedback.
Figure 1: Slovenian clinical centers (red dot) and regional hospitals (blue dot) which perform transabdominal preperitoneal as standard procedure for inguinal hernia. One regional hospital (yellow dot) intends to start performing transabdominal preperitoneal as a routine procedure in the year 2020

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The ZZZS, after meetings with the Slovenian Hernia Society, agreed to raise funds for bilateral inguinal hernia repair.

Results of raising incidence of performed TAPP procedures and total inguinal hernia operations are presented in [Figure 2] and [Figure 3], respectively.
Figure 2: Data on performed open unilateral inguinal hernia repair (predominantly Lichtenstein) in Slovenian hospitals between 2013 and 2018

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Figure 3: Data on performed unilateral and bilateral laparoscopic inguinal hernia repair (predominantly transabdominal preperitoneal) in Slovenian hospitals between 2013 and 2018

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  Discussion Top


Each year, >20 million operations are performed because of hernias worldwide.[15] In Germany, over 350,000 patients with hernias are operated annually, according to the Herniamed Registry.[16],[17] Similarly, in Austria, about 35,000 hernias are operated yearly, which makes an average of 4300 hernias/1 million inhabitants/year on average.[16],[17] In Slovenia, 3000 hernias/1 million inhabitants/year are operated annually.[18] The lower number of performed hernia repairs in Slovenia, compared to abovementioned countries Germany and Austria, is partly due to insufficient funding of hernia surgery in general and long waiting lists for hernia repair; the longest waiting list for surgery for patients with uncomplicated inguinal hernia (elective surgery) is 1.45 years (532 days) currently.[19]

Before 2012, for inguinal hernia repair, predominantly open approaches (Lichtenstein repair) were available in most hospitals in Slovenia. The need for implementation of laparoendoscopic techniques in inguinal hernia repair was not stimulated by health insurance, as no additional costs were covered for these procedures initially. Anyway, some enthusiastic surgeons introduced the laparoendoscopic techniques (TAPP and TEP) in their hospitals despite relative cost ineffectiveness and with a pure desire to fulfill the requirements of international guidelines.[13],[14] Growing awareness for implementing laparoendoscopic techniques, such as TAPP, reached critical mass for introducing positive changes in the year 2012. In this year, important weight to the arguments for TAPP was given at the Slovenian biennial hernia symposium by invited guests, especially Prof. Dr. Reinhard Bittner, who published the largest single-center series in TAPP.[20] It has been showed that implementing TAPP is possible in routine setting also in countries such as Slovenia, where hospitals are refunded for their medical (also surgical) procedures by the system of lump-sum reimbursement, which very often does not cover real costs.[21] This way of covering expenses to health providers, without respecting real price, is a typical remnant of an old health system or a health system in transition.[10],[11] To fulfill the plan of introducing TAPP technique into surgical repertoire of all Slovenian general hospitals, internal surgical/hospital budgets had to be rearranged partially, in order to make this decision acceptable and financially tolerable.[11],[21]

An additional important step toward standardization of TAPP in Slovenia was successful negotiations between the Slovenian Hernia Society and the ZZZS in 2016 for covering additional costs for bilateral inguinal hernia, as one of the most frequent indications for TAPP. Some progress has been achieved toward payment for bilateral hernia repairs, but we are still far away from real cost reimbursement for the TAPP procedure.[22]

Regardless of financial issues and in spite of not being supported accordingly by health insurance yet, the crucial step for introducing the TAPP technique in another clinical center and in nine regional hospitals was the way we implemented the EHS guidelines as standards into daily surgical practice. This plan and task has been strongly promoted by the Slovenian Hernia Society since 2012. In this period of time, about five hernia workshops were organized through the Slovenian Hernia Society in these hospitals in order to encourage local surgeons to perform the TAPP technique according to guidelines. At the beginning, all workshops and operations were planned as a demonstration of the TAPP technique, but soon local surgeons performed parts of operations under supervision till the procedure could be assisted completely by the proctor.[23] Due to the relatively small size of Slovenia and good response from local surgical departments, the TAPP method was introduced as one of the standards for inguinal hernia management in Slovenia with rising numbers of implementations [Figure 2] in a record time as a standard. At the same time, we proved according to our experience that the TAPP technique is a convenient procedure for training young surgeons.[23] According to [Figure 2] and [Figure 3], it is obvious that the total amount of open inguinal hernia repairs in Slovenia is reducing slowly but steadily because of the successful introduction of TAPP technique into daily practice. In the year 2017, there was an isolated small rise in total number of open inguinal hernia repairs due to additional funds from ZZZS in order to reduce the number of patients on the waiting lists for operation. A part of these repairs were performed as open procedures in day hospitals, where hospitalization was not possible. According to constant reducing of number of open inguinal repairs, the total number of performed laparoscopic inguinal hernia operations has started to rise since 2013 and is still growing in absolute numbers. In the year 2018, the TAPP versus Lichtenstein ratio for the management of inguinal hernia in Slovenia reached 14% (TAPP) vs. 86% (Lichtenstein), respectively. We expect the ratio to grow further in the future.

In order to maintain continuity for further development of the TAPP technique and introducing other hernia techniques in Slovenian hospitals, one or two surgeons in every local surgical department were named by the Slovenian Hernia Society as delegates who take the responsibility for planning further hernia surgery improvements in their environment. As a next important step in hernia quality control, the Slovenian Hernia Society intends introducing Herniamed Registry as a further quality management tool in Slovenian clinical centers and regional hospitals, starting the registry in two hospitals in 2019.[24]


  Conclusions Top


Availability of laparoscopic inguinal hernia repair in the 3rd millennium should be a must in every EU country. TAPP was quickly and successfully introduced and consolidated as a standard inguinal hernia repair technique in 12 hospitals across Slovenia in a relatively short period of 6 years (2013–2018). Full satisfaction will be achieved after the last of general hospitals in Slovenia (13 altogether) will perform TAPP as a routine and standard procedure on a daily basis. A good mentorship and support from national hernia society is essential in this project.[25]

Acknowledgment

The author would like to express his sincerest gratitude to Prof. Dr. Reinhard Bittner and M. D. Dr. H. C. Mult for the opportunity they have given us and for trust that they put into the Slovenian Hernia Society. We will work hard to maintain it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343-403.  Back to cited text no. 1
    
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Gass M, Scheiwiller A, Sykora M, Metzger J. TAPP or TEP for recurrent inguinal hernia? Population-based analysis of prospective data on 1309 patients undergoing endoscopic repair for recurrent inguinal hernia. World J Surg 2016;40:2348-52.  Back to cited text no. 3
    
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Niebuhr H, Wegner F, Hukauf M, Lechner M, Fortelny R, Bittner R, et al. What are the influencing factors for chronic pain following TAPP inguinal hernia repair: An analysis of 20,004 patients from the herniamed registry. Surg Endosc 2018;32:1971-83.  Back to cited text no. 17
    
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