title: The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair.
abstract: BACKGROUND
  Several laparoscopic techniques have been introduced to re pair inguinal hernia, the newest and most promising being a totally extraperitoneal approach. Nevertheless, the surgeon may encounter several complications and technical difficulties associated with the transition from the conventional anterior operation.
  
  
  METHODS
  In late 1993 and 1994, 120 patients were operated on for inguinal hernia using the totally extraperitoneal approach by four laparoscopic surgeons inexperienced in this new technique in a secondary referral setting. Their learning curve was assessed through operation time, perioperative and postoperative complications, and technical difficulties.
  
  
  RESULTS
  Median operative time decreased significantly (P = 0.0003) when going through the learning curve. During the initial part of the learning curve, conversion to another technique was necessary in 10 (8%) cases, and in 6 of these cases, conversion was needed for a peritoneal tear (relative risk for conversion if peritoneal tear was present: 4.0; 95% confidence interval 1.2 to 13.1, P = 0.025). The median operative time for Nyhus type IIIb and IVb hernias was significantly longer than for other types (70 versus 55 minutes, P = 0.003). Median postoperative stay was 2 days (range 0 to 7). There were 10 recurrences within 6 months due to technical or judgement errors.
  
  
  CONCLUSIONS
  For surgeons, the learning curve for totally extraperitoneal laparoscopic hernia repair can be overcome; however, the presence of an experienced surgeon during the procedure is vital, as this may prevent unnecessary recurrences.
authors.affiliation: Department of General Surgery, University Hospital Utrecht, The Netherlands.
authors.forename: M S
authors.initials: MS
authors.lastname: Liem
authors.forename: C J
authors.initials: CJ
authors.lastname: van Steensel
authors.forename: R U
authors.initials: RU
authors.lastname: Boelhouwer
authors.forename: W F
authors.initials: WF
authors.lastname: Weidema
authors.forename: G J
authors.initials: GJ
authors.lastname: Clevers
authors.forename: W S
authors.initials: WS
authors.lastname: Meijer
authors.forename: J P
authors.initials: JP
authors.lastname: Vente
authors.forename: L S
authors.initials: LS
authors.lastname: de Vries
authors.forename: T J
authors.initials: TJ
authors.lastname: van Vroonhoven
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D012008:Recurrence; D017211:Treatment Failure