A New Proposal for Learning Curve of TEP Inguinal Hernia Repair: Ability to Complete Operation Endoscopically as a First Phase of Learning Curve

Abstract

Background. The exact nature of learning curve of totally extraperitoneal inguinal hernia and the number required to master this technique remain controversial. Patients and Methods. We present a retrospective review of a single surgeon experience on patients who underwent totally extraperitoneal inguinal hernia repair. Results. There were 42 hernias (22 left- and 20 right-sided) in 39 patients with a mean age of 48.8 ± 15.1 years. Indirect, direct, and combined hernias were present in 18, 12, and 12 cases, respectively. The mean operative time was 55.1 ± 22.8 minutes. Peritoneal injury occurred in 9 cases (21.4%). Conversion to open surgery was necessitated in 7 cases (16.7%). After grouping of all patients into two groups as cases between 1–21 and 22–42, it was seen that the majority of peritoneal injuries (7 out of 9, 77.8%, P = 0.130) and all conversions (P = 0.001) occurred in the first 21 cases. Conclusions. Learning curve of totally extraperitoneal inguinal hernia repair can be divided into two consequent steps: immediate and late. At least 20 operations are required for gaining anatomical knowledge and surgical pitfalls based on the ability to perform this operation without conversion during immediate phase.

Extraperitonial Hernia Repair

“…The learning curve for any particular procedure is defined as the minimum number of cases needed to acquire adequate surgical skills and knowledge of pitfalls and technical aspects of the procedure with minimum operative time and decrease in complication rates. [9][10][11] In literature, various cutoff limits for the learning period of laparoscopic hernia repair have been recommended, reaching up to a minimum of 250 cases being regarded as comfort zone. 7 In another review, performing atleast 30 to 100 operations was suggested as a critical threshold level to become experienced surgeon.…”

The Learning Curve for Laparoscopic Totally Extraperitoneal Herniorrhaphy by Logarithmic Function

“…14 Appropriate patient selection is an important parameter for successful surgery during the early period of learning. 3 In the early period, TEP hernia repair may prudently avoid irreducible hernias and patients with previous lower quadrant surgery.…”

“…1 Since this technique does not require entry into the abdominal cavity and it is free from complications related to abdominal cavity entry, it has gained popularity in the recent two decades. 3 Advantages of TEP hernia repair include equivalent recurrence rates as the open technique with less neural pain, less hematoma occurrence, lower infection rate and short recovery period. Compared to TAPP hernia repair, TEP hernia repair has a shorter operation time and less possibility of damaging adjacent organs.…”

“…The nature of learning curve, the exact learning model and the number of repetitions needed to become sufficiently skilled at the technique are still unclear. 3 Assessment during the learning phase can include operating time, postoperative complications, and technical difficulties. 8,9 In this study, only the operating time was used as a parameter since it is an objective parameter that is easily measured and which can be readily applied to produce mathematical models.…”

Transversalis Fascia and Preperitoneal Fascia: A Laparoscopic Study of Live Surgical Anatomy during TEPP Hernioplasty – Final Report and Literature Review

“…[16,17] However, the learning curve of TEP hernioplasty is long and steep, and carries paramount importance for the beginners/ inexperienced surgeons. [18] The steep long learning curve is often discouraging to many surgeons who therefore declare the laparoscopic technique not worth for such a basic surgery. [19] 'Initially, the dissection of the extraperitoneal space in the TEP approach tended to be difficult, confusing and therefore hard to learn'.…”