title: Selecting patients during the "learning curve" of endoscopic Totally Extraperitoneal (TEP) hernia repair.
abstract: BACKGROUND
  Totally Extraperitoneal (TEP) hernia surgery is associated with little postoperative pain and a fast recovery, but is a technically demanding operative procedure. Apart from the surgeon's expertise, patient characteristics and hernia-related variations may also affect the operative time and outcome.
  
  
  METHODS
  Patient-related factors predictive of perioperative complications, conversion to open anterior repair, and operative time were studied in a cohort of consecutive patients undergoing TEP hernia repair from 2005 to 2009.
  
  
  RESULTS
  A total of 3,432 patients underwent TEP. The mean operative time was 26 min (SD ± 10.9), TEP was converted into an open anterior approach in 26 patients (0.8 %), and perioperative complications were observed in 55 (1.6 %) patients. Multivariable regression analysis showed that a history of abdominal surgery (OR 1.76, 95 per cent confidence interval 1.01-3.06; p = 0.05), and the presence of a scrotal (OR 5.31, 1.20-23.43; p = 0.03) or bilateral hernia (OR 2.25, 1.25-4.06; p = 0.01) were independent predictive factors of perioperative complications. Female gender (OR 5.30. 1.52-18.45; p = 0.01), a history of abdominal surgery (OR 3.96, 1.72- 9.12; p = 0.001), and the presence of a scrotal hernia (OR 34.84, 10.42-116.51, p < 0.001) were predictive factors for conversion. A BMI ≥ 25 (effect size (ES) 1.78, 95 % confidence interval 1.09-2.47; p < 0.001) and the presence of a scrotal (ES 5.81, 1.93-9.68; p = 0.003), indirect (ES 2.78, 2.05- 3.50, p < 0.001) or bilateral hernia (ES 10.19, 9.20-11.08; p < 0.001) were associated with a longer operative time.
  
  
  CONCLUSIONS
  Certain patient characteristics are, even in experienced TEP surgeons, associated with an increased risk of conversion and complications and a longer operative time. For the surgeon gaining experience with TEP, it seems advisable to select relatively young and slender male patients with a unilateral (non-scrotal) hernia and no previous abdominal surgery to enhance patient safety and 'surgeon comfort'.
authors.affiliation: Department of Surgery, Diakonessenhuis, Zeist, Professor Lorentzlaan 76, 3707 HL, Zeist, The Netherlands, nelleke.schouten@gmail.com.
authors.forename: N
authors.initials: N
authors.lastname: Schouten
authors.forename: J W M
authors.initials: JW
authors.lastname: Elshof
authors.forename: R K J
authors.initials: RK
authors.lastname: Simmermacher
authors.forename: T
authors.initials: T
authors.lastname: van Dalen
authors.forename: S G A
authors.initials: SG
authors.lastname: de Meer
authors.forename: G J
authors.initials: GJ
authors.lastname: Clevers
authors.forename: P H P
authors.initials: PH
authors.lastname: Davids
authors.forename: E J M M
authors.initials: EJ
authors.lastname: Verleisdonk
authors.forename: P
authors.initials: P
authors.lastname: Westers
authors.forename: J P J
authors.initials: JP
authors.lastname: Burgmans
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D061887:Conversion to Open Surgery / Q000706:statistics & numerical data; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D059032:Learning Curve; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D061646:Operative Time; D018579:Patient Selection; D010537:Peritoneum / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome