Learning Curve for Laparoscopic Repair of Pediatric Inguinal Hernia Using Percutaneous Internal Ring Suturing

Abstract

Background: Percutaneous internal ring suturing (PIRS) is a simple and popular technique for the treatment of inguinal hernia in children. The aim of this study was to analyze the learning curves during implementation of PIRS in our department. Methods: A total of 318 pediatric patients underwent hernia repair using the PIRS technique by three pediatric surgeons with different levels of experience in laparoscopic surgery. These patients were enrolled in a prospective cohort study during the period October 2015–January 2021. Surgical times, intraoperative and postoperative complications, in addition to outcomes of treatment were compared among the pediatric surgeons. Results: Regarding operative time a significant difference among the surgeons was found. Operative time significantly decreased after 25–30 procedures per surgeon. The surgeon with advanced experience in laparoscopic surgery had significantly less operative times for both unilateral (12 (interquartile range, IQR 10.5, 16.5) min vs. 21 (IQR 16.5, 28) min and 25 (IQR 21.5, 30) min; p = 0.002) and bilateral (19 (IQR 14, 21) min vs. 28 (IQR 25, 33) min and 31 (IQR 24, 36) min; p = 0.0001) hernia repair, compared to the other two surgeons. Perioperative complications, conversion, and ipsilateral recurrence rates were higher at the beginning, reaching the benchmarks when each surgeon performed at least 30 PIRS procedures. The most experienced surgeon had the lowest number of complications (1.4%) and needed a fewer number of cases to reach the plateau. The other two surgeons with less experience in laparoscopic surgery had higher rates of complications (4.4% and 5.4%) and needed a higher number of cases to reach the plateau (p = 0.190). Conclusions: A PIRS learning curve for perioperative and postoperative complications, recurrences, and conversion rates reached the plateau after each surgeon had performed at least 30 cases. After that number of cases PIRS is a safe and effective approach for pediatric hernia repair. A surgeon with an advanced level of experience in pediatric laparoscopic surgery adopted the technique more easily and had a significantly faster learning curve.

The Safety and Effectiveness of Laparoscopic Pyloromyotomy Using 3-mm Electrocautery Hook versus Open Surgery for Treatment of Hypertrophic Pyloric Stenosis in Infants

“…Last two to three decades laparoscopic surgery gained popularity among pediatric surgeons, especially after development of instruments suitable for the pediatric population. Various pediatric procedures such as hernia repair, varicocelectomy, cholecystectomy, appendectomy, pyloromyotomy etc., which until then had been performed exclusively by the open approach, began to be performed using laparoscopic approach [15][16][17][18][19][20][21][25][26][27][28][29]. Numerous studies reported benefits of laparoscopic approach for treatment of hypertrophic pyloric stenosis such as faster recovery, faster postoperative feeding, lesser pain, shorter surgical and hospitalization times and lower incidence of wound related complications [6,11,[15][16][17][18][19][20][21][22].…”

Comparison of Recurrence and Complication Rates Following Laparoscopic Inguinal Hernia Repair among Preterm versus Full-Term Newborns: A Systematic Review and Meta-Analysis

“…Considering all the above-mentioned facts, the surgical repair of inguinal hernia for PT newborns should be considered as a major procedure and performed only by consultants or senior residents under the supervision of consultants. The learning curve is longer compared to hernia surgery performed in FT infants and older children [3,6]. Generally, there is no need to rush surgery, but in PT newborns, a higher possibility of incarceration has been reported [21,27].…”

“…Unlike open surgery, the laparoscopic approach has several advantages and is associated with fewer complication rates. This includes the avoidance of dissecting the vas deferens and spermatic vessels, the possibility of inspection of the contralateral side, reduced pain, faster recovery, and better cosmetic outcome [3][4][5][6][7][8]10,19,20,30,34]. Several different laparoscopic techniques for pediatric inguinal hernia repair have been described, but these techniques can be divided into two major groups: traditional laparoscopic hernia repair, which includes intracorporeal suturing and requires the placement of multiple trocars, and percutaneous, needle-assisted techniques, without introducing multiple ports [5,6,10,11,35].…”

“…However, there exists a learning curve for the laparoscopic repair of pediatric inguinal hernia, especially in preterm newborns. A recent study demonstrated that the complication and recurrence rates plateau only after a surgeon performs at least thirty cases of laparoscopic-assisted percutaneous internal ring suturing [6].…”

Effects on Recovery of Pediatric Patients Undergoing Total Intravenous Anesthesia with Propofol versus Ketofol for Short—Lasting Laparoscopic Procedures

“…The most common elective surgical procedures in pediatric patients to which laparoscopy can be applied include procedures of the inguinoscrotal region, such as inguinal hernia repair, orchiopexy for abdominal testis, varicocelectomy, etc. [ 2 , 3 , 4 ].…”