Laparoscopic hernia repair: The learning curve

The performance of a laparoscopic inguinal hernia repair requires unique te chnical and cognitive skills which, until recently, were not routinely taug ht to general surgeons. The initial experience of three surgeons with lapar oscopic hernia repair was audited prospectively to assess the learning curv e for the technique. From March 1992 to June 1994, transabdominal preperito neal (TAP) mesh repair was attempted on 172 consecutive inguinal hernias. T hree procedures were convened to traditional repairs. The three independent surgeons that performed the repairs had minimal or no prior clinical exper ience with the technique in the role as primary surgeon. The hernia repairs were divided into two groups. Group 1 consisted of the first 90 hernia rep airs in the series, 30 repairs per surgeon. This group was compared to the subsequent 82 repairs (group 2), approximately 27 repairs per surgeon. Pati ents were followed up for a median of 31 months. Group 1 had more patients who were hospitalized overnight (37% versus 31%), a greater rate of convers ion (2.2% versus 1.2%), a higher complication rate (11.7% versus 0%), a hig her recurrence rate (12.2% versus 0%), and a longer delay in the return to full activity (11 weeks versus 8 weeks). Also, overall patient satisfaction with their hernia repair was slightly greater in group 2 (score, 9.0/10 ve rsus 8.2/10). The lack of prior experience with the TAP technique (one surg eon) was associated with a marked increase in the number of conversions (tw o of three total conversions), complications (four of eight total), and her nia recurrences (8 of ii total). This study demonstrates that a surgeon's i nitial experience with laparoscopic herniorrhaphy is associated with an ide ntifiable learning curve. Significant improvements in complication and recu rrence rates and overall patient satisfaction can be expected after the ini tial learning phase. Also, a complete lack of prior experience with laparos copic herniorrhaphy is associated with a higher rate of conversion and sign ificant increases in complications and hernia recurrences.