Totally extraperitoneal (TEP) approach for inguinal hernia: the favorable learning curve for trainees

Endoscopic inguinal herniorrhaphy has become an established approach to groin hernia. The use of a totally extraperitoneal (TEP) approach allows a tension-free, preperitoneal approach with potentially less discomfort and morbidity than do classic repairs. Concerns have been raised regarding excessive cost, need for general anesthesia, and an extensive learning curve for surgeon and resident trainee alike.

A retrospective analysis of 264 consecutive patients undergoing TEP for inguinal hernia repair from September 1995 to April 2000 was performed. All repairs were performed by surgical trainees under the supervision of a single staff surgeon.

Mean age of 256 men and 8 women undergoing 386 inguinal hernia repairs was 54 years (range, 15-86). Inguinal hernias were unilateral (n = 142) or bilateral (n = 122); indirect (52%), direct (33%), or pantaloon (15%); 37 defects (10%) were recurrent. Surgical residents (n = 74) participated in all 264 operations and were considered the "junior surgeon" in 211 cases: 19 chief residents did 35 operations, 9 PG-4s performed 27, 8 PG-3s did 17, 10 PG-2s completed 41, and 28 interns did 91 procedures. Mean operative time was 96 minutes (range, 30-261) with no statistical difference among PG-1s, 2s, 3s, 4s, or chief residents learning the procedure. Early postoperative complications included urinary retention (n = 25), seroma (n = 3), ileus (n = 3), and subcutaneous wound infection (n = 1). Fully 24% of patients desired or required overnight admission. All patients (100%) operated on for recurrence (n = 37) or a previous contralateral repair (n = 19) favored the current TEP approach over their prior repair. Hernia recurrence has developed in 8 patients, with 6 (75%) occurring within the first 40 study patients. Mean follow-up was 3.5 years (range, 1.2-5.9 years).

The totally extraperitoneal approach is a safe and effective method of inguinal hernia repair. Following a learning curve of 40 patients for the staff surgeon, the recurrence rate has been less than 1%, with surgical trainees safely performing TEP repairs under supervision.