title: Factors influencing on difficulty with laparoscopic total extraperitoneal repair according to learning period.
abstract: OBJECTIVE
  Laparoscopic total extraperitoneal (TEP) repair of inguinal hernia is technically challenging enough to build high barrier to entry. The purpose of this study was to identify clinical factors influencing technical difficulty with laparoscopic TEP according to learning period.
  
  
  METHODS
  We conducted a retrospective study of 112 adult patients who underwent laparoscopic TEP for unilateral inguinal hernia from January 2009 to September 2013. A technically difficult case was defined as the 70th percentiles or more in the distribution curve of operative time, major complication, or open conversion.
  
  
  RESULTS
  The rate of body mass index (BMI) above 25 kg/m(2) was significantly higher in the difficult group than the nondifficult group in the learning period of laparoscopic TEP (57.9% vs. 26.8%, respectively, P = 0.020). However, in the experience period, it revealed no statistical difference with technical difficulty (31.3% vs. 33.3%, respectively, P = 0.882). In multivariate analysis, BMI (≥25 kg/m(2)) was identified as a significant independent factor for technical difficulty with laparoscopic TEP in the learning period (odds ratio, 4.572; P = 0.015).
  
  
  CONCLUSIONS
  Patient's BMI (≥25 kg/m(2)) can create technical difficulty with laparoscopic TEP only in the learning period, but not in the experience period. Therefore BMI could be applied as one of the guidelines for patient selection, especially for surgeons in the learning curve of laparoscopic TEP.
authors.affiliation: Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea.
authors.forename: Byung Soo
authors.initials: BS
authors.lastname: Park
authors.affiliation: Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea.
authors.forename: Dong Yeon
authors.initials: DY
authors.lastname: Ryu
authors.affiliation: Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea.
authors.forename: Gyung Mo
authors.initials: GM
authors.lastname: Son
authors.affiliation: Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea.
authors.forename: Yong Hoon
authors.initials: YH
authors.lastname: Cho
keywords: Body mass index; Herniorrhaphy; Inguinal hernia; Laparoscopy; Learning curve