Achieving the Learning Curve in Laparoscopic Inguinal Hernia Repair by Tapp: A Quality Improvement Study

Background: More than 20 million patients worldwide undergo groin hernia repair annually. Every year more than 800,000 inguinal hernia repairs are performed in the United States alone. Since the first report by Ger et al. in 1990, laparoscopic inguinal hernia repair has gained wide acceptance due to its many advantages with more than 20% of inguinal hernias treated by this approach. The aim of our study is to estimate the number of cases needed over the course of a trainee's learning curve period to achieve stabilization of operating time and intra and post-operative complication rates when performing laparoscopic transabdominal preperitoneal hernia repair (TAPP). Methods: We analyzed data from the first 100 TAPP procedures performed by two different trainees (trainee A & B) and compared it with a homogeneous group of 100 procedures performed by a senior surgeon. Two tests were used to evaluate completion of the learning curve: the Cumulative Sum (CUSUM) and KPSS tests. The CUSUM test evaluated when the trainee's operative time became consistently similar to that of the senior surgeon, while the KPSS test evaluated when the trainee's operative time became stationary. Results: No differences in intra and post-operative data were noted between the three groups. The CUSUM test showed that trainee A completed his learning curve after 60 procedures, while trainee B completed it after 65 procedures. The KPSS test showed that the operative time stabilized after 20 procedures for trainee A and after 50 procedures for trainee B, respectively. Conclusions: Our evaluation shows that both trainees fully completed their learning curves for the TAPP after 65 procedures, providing us with a parameter which can be taken into consideration when establishing the minimum volume necessary to guarantee correct training in laparoscopic inguinal hernia repair by a TAPP technique.