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VOLUME 6 , ISSUE 2 ( May-August, 2021 ) > List of Articles

RESEARCH ARTICLE

Learning Curve in Laparoscopic Inguinal Hernia Repair

Sarvesh Maheshwari, Brijesh Kumar Sharma, Mahesh Chandra Misra

Keywords : Laparoendoscopic, Learning curve, totally extraperitoneal/transabdominal preperitoneal repair

Citation Information : Maheshwari S, Sharma BK, Misra MC. Learning Curve in Laparoscopic Inguinal Hernia Repair. J Mahatma Gandhi Univ Med Sci Tech 2021; 6 (2):48-52.

DOI: 10.5005/jp-journals-10057-0146

License: CC BY-NC 4.0

Published Online: 31-08-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Abstract

Background: There are two standardized techniques for the laparoendoscopic repair of inguinal hernia, i.e., transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP); however, both are associated with a steep learning curve. The objective of the present study was to define the learning curve of a laparoendoscopic inguinal hernia repair for both TEP repair and TAPP repair. Material and methods: In this prospective study, 85 patients with inguinal hernia posted for laparoendoscopic inguinal hernia repair using either TEP or TAPP were included to assess the learning curve. The learning curve was assessed for junior surgeon (otherwise experienced laparoscopic surgeon not performing laparoendoscopic groin hernia repair) under the direct supervision of senior surgeon (regularly performing laparoendoscopic groin hernia repair). The study period was between January 2018 and June 2019. A comparison was done based on patient demographics, details of operative procedure [TEP or TAPP, operative time, intraoperative difficulty, peritoneal laceration (TEP), vascular injury, conversion from TEP to TAPP, and/or open hernia repair] postoperative hospital stay, intraoperative complications, conversion rate, hospital stay in days, and postoperative complications. Results: Out of 85, 50 patients were operated by the senior surgeon (TAPP was done in 38 cases and TEP was done in 12) and 35 by the junior surgeon (TAPP was done in 14 cases and TEP in 20 and 1 case, i.e., 1.2% was converted from laparoscopic to open). There were 103 groin hernias in 85 patients in the study. Indirect, direct, and combined hernias were present in 39, 28, and 36, respectively. In our study, there was less prevalence of direct hernia, i.e., 32.8% out of which 38 and 62% were operated by the senior and junior surgeons, respectively, whereas 45.6% were indirect hernia out of which 40 and 60% were operated by the senior and junior surgeons, that shows its high prevalence. 17.6%, i.e., 15 cases were found to be bilateral hernia out of which 73.33% were operated by the senior surgeon while 82.4%, i.e., 70 cases were unilateral hernia out of which 60% were operated by the junior surgeon, statistically not significant (p = 0.44). The patients operated by the senior surgeon had higher mean age, i.e., 53 ± 17.43 years as compared to the junior surgeon, i.e., 46 ± 14.22 years (p value = 0.043) with statistically significant. Mean operating time by the senior surgeon was 49 ± 4.63 minutes, and 62 ± 4.20 minutes for the junior surgeon with a p value of 0.0005, statistically highly significant. 25.33% of patients had intraoperative complications and 24.13% of patients had a peritoneal injury. The surgeries done by the junior surgeon had 30% of peritoneal injury while it was 21.05% for the senior surgeon in the TEP procedure, statistically not significant (p = 0.56). Twenty percent of patients had postoperative complications out of which urinary retention was maximum, i.e., in 8 (9.4%) statistically insignificant with p = 0.71. Conclusion: The junior surgeon in the present study was highly experienced and accomplished in laparoscopic surgery with over 15 years of experience but not performing laparoendoscopic groin hernia repair; that seems to be the reason for a fewer number of procedures (8 for TAPP and 9 for TEP) required to overcome the learning curve. Therefore, surgeons with excellent laparoscopic skills need a shorter learning curve as compared to the beginner in laparoscopic surgery, when it comes to laparoendoscopic groin hernia repair.


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  1. Wantz GE. Abdominal wall hernias. In: Schwartz SI, ed. Principles of surgery. 7th ed., New York, NY: Mcgraw-Hill; 1999. pp. 1585–1611.
  2. Malangoni MA, Rosen MJ. Hernias. In: Townsend CM, Beauchamp RD, Evers BM, et al., ed. Sabiston textbook of surgery. Pennsylvania, PA: Saunders Elsevier; 2010. p. 1155, 1160-1.
  3. Manthey D, Nicks BA, Hernias. Available from: http://www.e-medicine.com/emerg/topic251.htm. [Last accessed on 2014 Nov 15].
  4. Mcintosh A, Hutchinson A, Roberts A, et al. Evidence-based management of groin hernia in primary care – a systematic review. Fampract 2000;17(5):442–447. DOI: 10.1093/fampra/17.5.442.
  5. Bax T, Sheppard BC, Crass RA. Surgical options in the management of groin hernias. Am Fam Physician 1999;59(4):893–906.
  6. Dulucq JL. Treatment of inguinal hernias by inserting a subperitoneal prosthetic patch using pre-peritoneoscopy (with a video film). Chirurgie: Memoires de l'Academie de Chirurgie 1992;118(1-2):83–85. (French).
  7. Lau H, Patil NG, Yuen WK, et al. Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Surg Endoscopy Andother Intervent Techniq 2002;16(12):1724–1728. DOI: 10.1007/s00464-001-8298-0.
  8. Choi YY, Kim Z, Hur KY. Learning curve for laparoscopic totally extraperitoneal repair of inguinal hernia. Canadian J Surg 2012;55(1):33–36. DOI: 10.1503/cjs.019610.
  9. Lal P, Kajla RK, Chander J. Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve. Surg Endosc 2004;18(4):642–645. DOI: 10.1007/s00464-002-8649-5.
  10. Edwards CCII, Bailey RW. Laparoscopic hernia repair: the learning curve. Surg Laparosc Endosc Percutan Tech 2000;10(3):149–153. DOI: 10.1097/00019509-200006000-00010.
  11. Voitk AJ. The learning curve in laparoscopic inguinal hernia repair for the community general surgeon. Can J Surg 1998;41(6):446–450.
  12. Mckernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993;7(1):26–28. DOI: 10.1007/BF00591232.
  13. Suguita FY, Essu FF, Oliveira LT, et al. Learning curve takes 65 repetitions of totally extraperitoneal laparoscopy on inguinal hernias for reduction of operating time and complications. Surg Endosc 2017;31(10):3939–3945. DOI: 10.1007/s00464-017-5426-z.
  14. Filipi CJ, Fitzgibbons Jr RJ, Salerno GM, et al. Laparoscopic herniorrhaphy. Surg Clin North Am 1992;72(5):1109–1124. DOI: 10.1016/s0039-6109(16)45835-4.
  15. Fitzgibbons Jr RJ, Salerno GM, Flipi CJ, et al. Laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia. Ann Surg 1994;219(2):144–156. DOI: 10.1097/00000658-199402000-00006.
  16. Ger R, Mishrick A, Hurwitz J, et al. Management of groin hernias by laparoscopy. World J Surg 1993;17:46–50. DOI: 10.1007/BF01655704.
  17. Felix EL, Michas C. Double-buttress laparoscopic herniorrhaphy. J Laparoendosc Surg 1993;3(1):1–8. DOI: 10.1089/lps.1993.3.1.
  18. Bansal VK, Krishna A, Misra MC, et al. Learning curve in laparoscopic inguinal hernia repair: experience at a tertiary care centre. Indian J Surg 2016;78(3):197–202. DOI: 10.1007/s12262-015-1341-5.
  19. Schouten N, Elshof JWM, Simmermacher RKJ, et al. Selecting patients during the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair. Hernia 2013;17(6):737–743. DOI: 10.1007/s10029-012-1006-2.
  20. Mihăileanu F, Chiorescu S, Grad O, et al. The surgical treatment of inguinal hernia using the laparoscopic totally extra-peritoneal (TEP) technique. Clujul Med 2015;88(1):58–64. DOI: 10.15386/cjmed-396.
  21. Misra MC, Bansal VK, Kumar S, et al. Total extra-peritoneal repair of groin hernia: prospective evaluation at a tertiary care center. Hernia 2008;12(1):65–71. DOI: 10.1007/s10029-007-0281-9.
  22. Bökeler U, Schwarz J, Bittner R, et al. Teaching and training in laparoscopic inguinal hernia repair (TAPP): Impact of the learning curve on patient outcome. Surg Endosc 2013;27(8):2886–2893. DOI: 10.1007/s00464-013-2849-z.
  23. Hasbahceci M, Basak F, Acar A, et al. A new proposal for learning curve of TEP inguinal hernia repair: ability to complete operation endoscopically as a first phase of learning curve. Minim Invasive Surg 2014;2014:528517. DOI: 10.1155/2014/528517.
  24. Kim MJ, Hur KY. Laparoscopic totally extraperitoneal inguinal hernia repair: 10-year experience of a single surgeon. Surg Laparosc Endosc Percutaneous Tech 2013;23(1):51–54. DOI: 10.1097/SLE.0b013e31826e5022.
  25. Kwon OC, Baik YH, Oh MG, et al. The learning curve for laparoscopic totally extraperitoneal herniorrhaphy by logarithmic function. J Minim Invasive Surg 2016;19(4):126–129. DOI: 10.7602/jmis.2016. 19.4.126.
  26. Mathur S, Lin SYS. The learning curve for laparoscopic inguinal hernia repair: a newly qualified surgeon perspective. J Surg Res 2016;205(1):246–251. DOI: 10.1016/j.jss.2016.06.041.
  27. Vărcuş F, Duţă C, Dobrescu A, et al. Laparoscopic repair of inguinal hernia TEP versus TAPP. Chir 2016;111(4):308–312.
  28. Lim JW, Lee JY, Lee SE, et al. The learning curve for laparoscopic totally extraperitoneal herniorrhaphy by moving average. J Korean Surg Soc 2012;83(2):92–96.
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