The Learning Curve for Laparoscopic Inguinal Hernia Repair: an Analysis of the First 109 Cases

Laparoscopic inguinal hernia repair, especially the transabdominal preperitoneal (TAPP) approach, is being performed increasingly worldwide. However, more complications are reported due to inadequate skills. Here, we generate a learning curve associated with TAPP performed in one inguinal hernia center. A total of 109 consecutive TAPP cases performed by a single surgeon were collected between 2011 and 2013 at Qilu Hospital of Shandong University, China. The cumulative sum (CUSUM) analysis was introduced to evaluate the completion of the learning curve. Meanwhile, other surgical observational targets and complications before discharge and during follow-up were analyzed to evaluate the impact of the learning curve. The mean operation time was 77.8 ± 33.3 min. CUSUM analysis indicated that the major inflection point of was at case 30, which divided the learning curve into two phases (phase 1 and phase 2). Differences in operation time and the postoperative length of stay between the two phases achieved statistical significance (102.4 ± 46.3 vs 68.5 ± 20.5 min, P < 0.001, and 2.5 ± 0.8 vs 1.4 ± 0.7 days, P < 0.001, phase 1 vs phase 2). Complications, including recurrence, postoperative pain, bleeding, infection, seroma, urinary retention, and edema of scrotum distention, exhibited no statistical differences between phases before discharge or during 7-year follow-up. The learning curve for TAPP is completed after 30 cases. Complication rates remained unchanged throughout the learning curve. It provides us with parameters for the development of the training system.