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      The learning curve for laparoscopic totally extraperitoneal herniorrhaphy by moving average

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          Abstract

          Purpose

          Laparoscopic totally extraperitoneal (TEP) herniorrhaphy has been recognized as a treatment option for inguinal hernia. The objective of this study was to clarify the learning curve for laparoscopic TEP herniorrhaphy using the moving average method.

          Methods

          A total of 90 patients underwent laparoscopic TEP herniorrhaphy by a single surgeon between March 2009 and March 2011. We analyzed medical records including the demographic data, operating time, hospital stay, and postoperative complications.

          Results

          The mean operating time of the initial 30 cases (learning period group) was 66.3 minutes. After the initial 30 cases were performed, the time decreased to 52.8 minutes in the later 60 cases (experienced period group, P = 0.015). This represents the operating time becoming stabilized and then decreasing as the number of performed cases accumulates. Hospital stay was shorter and frequency of pain control, and complication rate were lower in the experienced period, however, there was no statistical significance.

          Conclusion

          We suggest that number of patients needed for the learning curve for laparoscopic TEP herniorrhaphy should be 30 cases. The operating time for laparoscopic TEP herniorrhaphy stabilizes after 40 cases in moving average analysis.

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          Defining a learning curve for laparoscopic colorectal resections.

          C Schlachta, R Grégoire, Shekhar Seshadri … (2001)
          The purpose of this review was to define the learning curve for laparoscopic colorectal resections. A prospectively accumulated, computerized database of all laparoscopic colorectal resections performed by three surgeons between April 1991 and March 1999 was reviewed. A total of 461 consecutive resections were evenly distributed among three surgeons (141, 155, and 165). Median operating time was 180 minutes for Cases 1 to 30 in each surgeon's experience and declined to a steady state (150-167.5 minutes) for Cases 31 and higher. Subsequently, Cases 1 to 30 were considered "early experience," whereas Cases 31 and higher were combined as "late experience" for statistical analysis. There were no significant differences between patients undergoing resections in the early experience and those undergoing resections in the late experience with respect to age, weight, or proportion of patients with malignancy, diverticulitis, or inflammatory bowel disease. There were greater proportions of males (42 vs. 54 percent, P = 0.046) and rectal resections performed (14 vs. 32 percent, P = 0.002) in the late experience. Trends toward declining rates of intraoperative complications (9 vs. 7 percent, P = 0.70) and conversion to open surgery (13.5 vs. 9.7 percent, P = 0.39) were observed with experience. Median operating time (180 vs. 160 minutes, P < 0.001) and overall length of postoperative hospital stay (6.5 vs. 5 days, P < 0.001) declined significantly with experience. There was no difference in the rate of postoperative complications between early and late experience (30 vs. 32 percent, P = 0.827). The learning curve for performing colorectal resections was approximately 30 procedures in this study, based on a decline in operating time, intraoperative complications, and conversion rate. Learning was also extended to clinical care because it was appreciated that patients could be discharged to their homes more quickly.
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            The learning curve for laparoscopic cholecystectomy. The Southern Surgeons Club.

            Nigel Bennett, Robert Moore (1995)
            The use of laparoscopic surgical procedures without previous training has grown rapidly. At the same time, there have been allegations of increased complications among less experienced surgeons. Using multivariate regression analyses, we evaluated the relationship between bile duct injury rate and experience with laparoscopic cholecystectomy for surgeons in the Southern Surgeons Club. Fifty-five surgeons performed 8,839 procedures. Fifteen bile duct injuries (by 13 surgeons) resulted with 90% of the injuries occurring within the first 30 cases performed by an individual surgeon. Multivariate analyses indicated that the only significant factor associated with an adverse outcome was the surgeon's experience with the procedure. A regression model predicted that a surgeon had a 1.7% chance of a bile duct injury occurring in the first case and a 0.17% chance of a bile duct injury at the 50th case. While surgeons appear to learn this procedure rapidly, institutions might consider requiring surgeons to move beyond the initial learning curve before awarding privileges.
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              Prospective, comparative study of postoperative quality of life in TEP, TAPP, and modified Lichtenstein repairs.

              Amy Lincourt, David A Klima, B. Todd Heniford … (2011)
              The purpose of this study was to compare postoperative quality of life (QOL) in patients undergoing laparoscopic totally extraperitoneal (TEP), transabdominal preperitoneal (TAPP), or modified Lichtenstein (ML) hernia repairs. The International Hernia Mesh Registry (2007-2010) was interrogated. 2086 patients who underwent 2499 inguinal hernia repairs were identified. A Carolinas Comfort Score was self-reported at 1-, 6-, 12-months and results were compared. Subgroups analysis and logistic regression were used to identify confounders and to control for significant variables. One hundred seventy-two patients met the exclusion criteria. The distribution of unilateral procedures was TEP (n = 217), TAPP (n = 331), and ML (n = 953). Average follow-up was 12 months. Use of >10 tacks, lack of prostate pathology, recurrent hernia repairs, and bilateral hernia repairs were significant predictors of postoperative pain. One month after surgery 8.9%, 16.6%, and 16.5% were symptomatic for TEP (P = 0.038 vs. ML), TAPP and ML, respectively. At 6 months and 1 year no differences were observed. The number of tacks used varied significantly, with 18.1% of TAPP and 2.3% of TEP with >10 tacks (P = 0.005). The incidence of hernia recurrences were equivalent: TEP (0.42%), TAPP (1.34%), and ML (1.27%). The number or type of tacks utilized did not impact recurrence rates. Use of >10 tacks doubles the incidence of early postoperative pain while having no effect on rates of recurrence. There was no difference in chronic postoperative pain comparing ML, TEP, and TAPP including when controlled for tack use.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Korean Surg Soc
                Journal ID (iso-abbrev): J Korean Surg Soc
                Journal ID (publisher-id): JKSS
                Title: Journal of the Korean Surgical Society
                Publisher: The Korean Surgical Society
                ISSN (Print): 2233-7903
                ISSN (Electronic): 2093-0488
                Publication date (Print): August 2012
                Publication date (Electronic): 25 July 2012
                Volume: 83
                Issue: 2
                Pages: 92-96
                Affiliations
                Department of Surgery, Konyang University College of Medicine, Daejeon, Korea.
                [1 ]Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, Korea.
                Author notes
                Correspondence to: Sang Eok Lee. Department of Surgery, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 302-718, Korea. Tel: +82-42-600-8956, Fax: +82-42-543-8956, srglee@ 123456hanmail.net
                Article
                DOI: 10.4174/jkss.2012.83.2.92
                PMC ID: 3412190
                PubMed ID: 22880183
                SO-VID: baf20c45-a101-4fec-bfbb-9166a00c7836
                Copyright © Copyright © 2012, the Korean Surgical Society
                License:

                Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 27 December 2011
                Date revision received : 07 May 2012
                Date accepted : 26 May 2012
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Surgery
                Keywords: tep,laparoscopy,moving average,inguinal hernia,learning curve
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: tep, laparoscopy, moving average, inguinal hernia, learning curve

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