Learning Curves for Laparoscopic Repair of Inguinal Hernia and Communicating Hydrocele in Children

Abstract

Introduction: We analyzed the department and surgeon learning curves during implementation of the percutaneous internal ring suturing (PIRS) technique in our department.

Methods: Children proposed for inguinal hernia or communicating hydrocele repair were included (n = 607). After mentorship, all surgeons were free to propose open or PIRS repair. From gathered data, we assessed department and surgeon learning curves through cumulative experience focusing in perioperative complications, conversion, ipsilateral recurrence, postoperative complications, and metachronous hernia, with benchmarks defined by open repair.

Results: Department-centered analysis revealed that perioperative complications, conversion, and ipsilateral recurrence rates were higher in the beginning, reaching the benchmarks when each surgeon performed, at least, 35 laparoscopic repairs. Postoperative complications and metachronous hernia rates were independent from learning curves, with the metachronous hernia rate being significantly lower in PIRS patients. During the program, the percentage of males in those operated by PIRS progressively increased reaching the percentage of males, in our sample, when department operated over 230 cases.

Conclusion: Thirty-five laparoscopic cases per surgeon are required for perioperative complications, conversion, and ipsilateral recurrence reach the benchmark. The gap between the percentage of males, in those operated by PIRS and in those proposed for surgery, monitors the confidence of the team in the program.

Keywords: children; communicating hydrocele; inguinal hernia; laparoscopy; learning curve; percutaneous internal ring suturing.

Figures

Figure 1

Femoral vein puncture, a perioperative complication. The procedure was interrupted, and the bleeding was controlled with external compression.

Figure 2

Inguinal foreign-body reaction, a postoperative complication emerging 4 weeks after surgery.

Figure 3

Department-centered analysis of the learning curve of percutaneous internal ring suturing (PIRS) technique considering (A) perioperative and (B) postoperative complications rates and (C) ipsilateral recurrence rate. p < 0.05 indicated significance: * vs. open; § vs. lap (0–114).

Figure 4

Confidence of the surgical team on the technique reflected by (A) conversion to open surgery rate, and (B) rate of male gender proposed for percutaneous internal ring suturing (PIRS). In (B), the full horizontal line represents the overall rate of males among our population. p < 0.05 indicated significance: * vs. overall prevalence; § vs. lap (0–114); †vs. lap (114–228).

Figure 5

Surgeon-centered analysis of the learning curve of percutaneous internal ring suturing (PIRS) technique. The graph reflects the cumulative experience of five staff surgeons throughout their first 50 surgeries by PIRS. The performance was evaluated by the (A) rate of perioperative complications, (B) rate of ipsilateral recurrence, and (C) rate of conversion to open surgery. The dotted lines represent the tendency lines. The dashed vertical line crossing the x-axis at point 35 marks the end of the learning curve, as no events occur after the 35th case of each surgeon.