Learning Curve Analysis of Laparoscopic Intracorporeal Sac Transection and Purse-String Suture for Pediatric Inguinal...

Background: Although various laparoscopic techniques are available for pediatric hernia repair, the learning curve for laparoscopic intracorporeal sac transection with purse-string suture (LIST-PS) has not yet been established. Considering that intracorporeal suturing is technically more challenging than extracorporeal knotting, an objective assessment of surgical competence is crucial. The study aimed to evaluate the learning curve and safety profile of LIST-PS performed by a single surgeon in a large series of pediatric patients. Methods: A retrospective analysis of 469 pediatric patients treated between March 2019 and December 2025 was conducted. The learning curve was assessed using the cumulative sum (CUSUM) analysis of operative times. The cohort was divided into phases 1 (learning) and 2 (proficiency) based on the CUSUM peak. Additionally, a high-risk subgroup (preterm infants aged < 1 year) was compared with a control group to evaluate the impact of patient complexity on surgical progress. Results: The mean patient age was 3.4 ± 3.5 years, and 29.4% were born prematurely. The CUSUM analysis identified a peak at case 233, marking the transition to proficiency. The mean operative time decreased significantly from 70.6 ± 26.3 min in phase 1 to 52.0 ± 16.5 min in phase 2 (p < 0.001). Despite the reduction in operative time, the recurrence rate remained stable at 1.7% in both phases (p > 0.999). In a subgroup analysis, the high-risk group (preterm infants and infants < 1 year) required longer operative times (73.5 ± 32.8 min vs. 57.7 ± 19.2 min; p < 0.001) but showed no significant difference in recurrence compared to the control group (0.96% vs. 1.92%; p = 0.691). Conclusions: Technical proficiency in LIST-PS was achieved after 233 cases. Although high-risk patients consistently required more time, the surgeon's improvement followed a parallel trajectory across all risk levels, maintaining high surgical safety throughout the learning process.