Crucial points in phases of totally extraperitoneal (TEP) hernia repair. Learning curve analysis

Totally extra-peritoneal (TEP) repair technique is one of the most used laparoscopic techniques for inguinal hernia repair. This study aimed to investigate the learning curve of technique and phases involved to help guiding novice learners.

Box-Jenkinson method for time series analysis and moving average method for standard deviation (SD) analysis and were employed for group determination and learning curve evaluation. Three individual groups were created based on the statistical analysis results and each group has been evaluated to determine the accuracy of the learning phases.

The learning phases of the technique were classified as: (1) Phase 1 (1st-28th case), (2) Phase 2 (29th-98th case), and Phase 3 (after 99th case). Operation time was statistically different between each phase. In addition, the number of intra-operative incidents was also found to be statistically different between phase-1 and other phases, with phase-1 being unfavorable.

To our knowledge, this is the first study that describes phases of learning the TEP hernia repair and compares these phases in terms of complication and operative time. We recommend that novice surgeons take extra care in terms of the selection of their patients during their first 28 cases and broaden their patient spectrum after the 63rd case. The learning curve of the TEP technique has three phases and each step must be carefully considered for patient selection so that milestones can be achieved as smoothly as possible without any complications.

Hernia, Laparoscopy, Learning curve, Moving average, TEP.