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Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernia: Learning Curve for Attending Surgeons and Residents

Saturday, October 20, 2012
Napoleon Ballroom (Hilton Riverside)
Jyoji Yoshizawa, Syuichi Ashizuka, Naruo Kuwashima, Masashi Kurobe, Keichiro Tanaka, Shinsuke Ohashi, Tomomasa Hiramatsu, Yuji Baba and Takao Ohki, Surgery, Jikei University School of Medicine, Tokyo, Japan

Purpose: Laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia is a simplified techniquein which a circuit suture made of nonabsorbable thread is placed extraperitoneally around the hernia orifice by a special suture needle (Lapaherclosure). Concerns have been raised about the extensive learning curve for both attending surgeons and residents.  This study assesses the difference in learning curves for the safe performance of LPEC by attending surgeons and residents.

Methods: A retrospective analysis was performed on the surgical charts of 409 consecutive patients (161 girls, 248 boys) who had undergone LPEC for inguinal hernia repair from December 2005 to December 2011 at Jikei University Hospital.  LPEC was performed by 3 attending surgeons and 4 residents who had not previously performed LPEC. The residents performed LPEC under staff guidance.  Each resident repaired form 24 to 79 LPEC procedures.  During LPEC, a 5-mm laparoscope was placed through an umbilical incision, a 2-mm grasping forceps was inserted on the left side of the umbilicus, and a 19-gauge Lapaherclosure was inserted at the midpoint of the right or left inguinal line.  The hernia sac orifice was closed extraperitoneally by circuit suturing around the internal inguinal ring using the Lapaherclosure.  The number of operative cases needed by attending surgeons and residents to reach the appropriate operation time was analyzed by the Mann-Whitney’s U test.

Results: The standard operation time for LPEC by attending surgeons who have performed more than 100 LPEC cases safely is about 30 minutes.  In our study, the attending surgeons needed 12 operation cases (range, 10 to 16) to reach 30 minutes for LPEC.  Three residents needed 31 operation cases (range, 27 to 33) to reach 30 minutes for LPEC.  The fourth resident could not perform LPEC in under 30 minute.  There was a statistical difference between the numbers of cases needed by the attending surgeons and the residents to perform LPEC safely (p<0.05). The overall incidence of contralateral patent processus vaginalis was 47.9%. No complications occurred during surgery.  The recurrence rate was 0.7% (recurrence in 3 boys).  Three wound infection cases occurred after surgery.  No testicular atrophy occurred after surgery.

Conclusion: LPEC has become a standard procedure in Japan.  Advantages of LPEC for inguinal hernia in children are that it may carry a lower risk of injuries of the spermatic cord and gonadal vessels and may also be useful for preventing contralateral inguinal hernia.  Our learning curve analysis showed that whereas attending surgeons need a mean of 12 operation cases to perform LPEC repairs safely in less than 30 minutes, residents need more than 30 operation cases to safely perform LPEC repairs without supervision.