Page 97 - International guidelines for groin hernia management

Hernia

endoscopic TEP shows some variation; however, it appears
that, on average, more than 100 repairs are required to
achieve outcomes comparable with open anterior mesh
repair. Around 100 repairs represent about a 40% higher
case number to achieve proficiency in TEP compared to
open IH mesh repair. There is limited evidence that the
learning curve may flatten after about 400 procedures. 15
More experience is likely required to achieve expert center
outcomes.

Figure 7: Reported recurrence rates (% in y axis) in six
published studies correlated with case numbers. Note most
studies reported using 10–15 cm polypropylene mesh for
repair. 15, 16, 19, 25–27
Learning Curve: Laparo-endoscopic Repair, TAPP
Approach
Similar to TEP repair, TAPP repair appears to have a
distinct learning curve compared to open anterior mesh
repair. Five studies have addressed the topic, 28–32 two of
28, 29
them from the same center. The development and
learning of the TAPP repairs appears to be included in
Figure 5: Published complications rates (% in y axis) 28
study. After 300 repairs by the pioneers, complications
correlated with case numbers. Complication rates for open
and recurrences decreased significantly and these successes
IH repair captured for [ 4000 patients in the NSQIP data were passed on to subsequent trainees under well defined
base are reported as 3%. 15–22 28, 29
and rigorous training conditions. Notably, the program
trainees experienced an operative time learning curve
similar to the pioneers and were still considered trainees
after they had performed [ 200 individual procedures.
Another study 31 also reported on all results including the
initial learning curve and stated that recurrence rates
improved after 200 cases, as the mesh size was changed to
a larger mesh. A different study 32 reported that there were
significant improvements in conversions and admissions
after 50 cases. Complication rates were halved, but were
still 16% and did not reach statistically significant differ-
ences from the initial rates (32%). We can thus extrapolate
that the learning curve to get to outcomes comparable with
open IH repair may have been longer.
Teaching: Open Hernia Repair
The literature search for teaching open hernia repair
revealed two procedure-specific papers. One 33 found that
any simulation (high tech, low tech) improved performance
over standard training with interactive simulation training
Figure 6: Reported operative time (minutes in y axis) in
six studies. 15, 17, 19, 21, 23, 24 correlated with case number. showed the most improvement. Components of training are
the understanding of anatomy, understanding of procedure
Note the mean time reported for general surgeons (not
steps and acquisition of technical skills; however, teaching
trainees) in NSQIP comprising [ 4000 cases is
45 min/case. 20

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