Outcomes and Learning Curve in Total Extraperitoneal Hernia Repair: A Cross-sectional Study

Abstract

Introduction: A hernia surgery can be performed via the classical open technique, or laparoscopically. However, the later techniques i.e, total extraperitoneal repair and transabdominal preperitoneal techniquesare allied to a steep learning curve. Aim: To define the learning curve associated with a Total Extraperitoneal (TEP) in inguinal hernia repair. Materials and Methods: A cross sectional study was conducted in Department of Surgery at Mahatma Gandhi Hospital, Jaipur, Rajasthan, India, from January 2018 and January 2022. Total 125 patients with inguinal hernia posted for laparoscopic inguinal hernia repair by a TEP technique, to assess the learning curve using the moving average method. Two surgeons i.e, surgeon 1 (assessee, junior surgeon) and surgeon 2 (assessor, senior surgeon) were chosen. The learning curve was assessed for surgeon 1, who was a general laparoscopic surgeon, not performing laparoscopic hernia repair, while surgeon 2 was regularly performing laparoscopic hernia repairs. A direct comparison was made, based on operative time, peritoneal laceration, vascular injury, conversionrates, hospital stay and complications. Results: Out of 125 patients, 50 patients were operated by the surgeon1 and 75 were operated by surgeon 2. Mean operating time by surgeon 2 was 52±4.5 minutes, and 66±4.18 minutes for surgeon 1 with a p-value of 0.0005. This was the only statistically significant variable, while hospital stay and surgical complications like peritoneal laceration, vascular injury or conversions to TAPP were statistically insignificant (p-value <0.05). Surgeon 1 (assessee) required to perform 10 TEP surgeries to overcome the learning curve. Oral intake was started at mean of postoperative day 1.08±0.32 for surgeon 1 and 1.04±0.20 for surgeon 2. Full diet was initiated on postoperative day 1.5±0.5 for senior surgeon, while 2.08±0.8 days for the junior surgeon. Conclusion: Surgeons with a prior experience in laparoscopic surgery needs a shorter learning curve ascompared to a beginner in laparoscopic surgery, when it comes to laparoendoscopic groin hernia repair.