Learning Curve in Laparoscopic Inguinal Hernia Repair

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.