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Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair?

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Abstract

Background

An important challenge of totally extraperitoneal (TEP) hernia repair is the learning curve. The European guidelines suggest that the learning curve ranges between 50 and 100 procedures, with the first 30–50 being critical. Others suggest that optimal outcomes are achieved after 200 or more TEP procedures.

Methods

All TEP repairs performed between 2005 and 2009 were included in this study. The effect of (surgeon) expertise on perioperative complications, conversion to open anterior repair, and operative time was assessed to evaluate the extent of the learning curve of TEP repair.

Results

Intraoperative complications occurred in <1 % of the 3,432 patients and postoperative complications were observed in 243 (7 %) patients. With a median follow-up of 2 years after TEP, 19 patients (0.55 %) had a recurrence. During the study period, at the end of which all four surgeons had treated 900–1,000 patients, intraoperative complications and recurrences did not decline. On the other hand, the median operative time decreased from 30 to 20 min (p < 0.001). The conversion rate (1.6–0.2 %, p = 0.018) and postoperative complication rate (11.6–4.2 %, p < 0.001) also declined. The decline was observed for all four surgeons, irrespective of their initial expertise with TEP. The largest decrease in the conversion rate was seen after at least 250 TEP procedures; the postoperative complication rate and operative time showed a linear and significant decline throughout the study period. A more or less “steady state” was observed after approximately 450 procedures per surgeon.

Conclusions

Even after more than 400 individually performed TEP procedures, there is progress in reducing the conversion rate, the incidence of short-term postoperative complications, and operative time, indicating a rather long learning curve.

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Disclosures

The authors confirm that Johnson and Johnson has assigned a Research Grant to the Diakonessenhuis. This research grant is intended to (partially) support all research regarding the results and complications of the endoscopic Totally Extraperitoneal (TEP) hernia repair. This study and/or this manuscript were not directly subject of the Research Grant. Johnson and Johnson had no access to data upon which the manuscript is based. A copy of the manuscript was provided only on the submitting date. Johnson and Johnson had no influence on the (subject of) this study whatsoever. Objectivity of data is therefore guaranteed and there is no conflict of interest. The authors have no (other) commercial associations that might pose a conflict of interest in connection with the submitted article.

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Authors and Affiliations

  1. Department of Surgery, Diakonessenhuis, Secretariaat Heelkunde, Professor Lorentzlaan 76, 3707 HL, Zeist, The Netherlands

    N. Schouten, T. van Dalen, N. Smakman, G. J. Clevers, P. H. P. Davids, E. J. M. M. Verleisdonk & J. P. J. Burgmans

  2. Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands

    R. K. J. Simmermacher

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  1. N. Schouten
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  2. R. K. J. Simmermacher
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  3. T. van Dalen
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  4. N. Smakman
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  5. G. J. Clevers
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  6. P. H. P. Davids
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  7. E. J. M. M. Verleisdonk
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  8. J. P. J. Burgmans
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Corresponding author

Correspondence to N. Schouten.

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Schouten, N., Simmermacher, R.K.J., van Dalen, T. et al. Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair?. Surg Endosc 27, 789–794 (2013). https://doi.org/10.1007/s00464-012-2512-0

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  • DOI: https://doi.org/10.1007/s00464-012-2512-0

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