Fellowship Training Eliminates the Learning Curve for Laparoscopic Inguinal Hernia Repair

Tiffany C Cox, MD, Jonathan P Pearl, MD FACS, Dionne Parreno, MD, Robert Moore, BS, E. Matthew Ritter, MD FACS. National Capital Consortium Bethesda, Maryland

INTRODUCTION: It has been suggested that as many as 250 laparoscopic inguinal hernia repairs are required for surgeons to achieve mastery. This number is based on the learning curves of the pioneers of the procedure, teaching themselves based solely on their own clinical experience. Increasingly, surgeons complete Minimally Invasive Surgery (MIS) fellowship training, which should significantly reduce or eliminate this learning curve.
METHODS: We performed a retrospective chart review of the initial post fellowship experience of two MIS trained surgeons performing laparoscopic inguinal hernia repairs from a single institution from August 2004-July 2009. Our electronic medical record was reviewed for any hernia related medical encounters across the entire military healthcare system. A telephone follow up survey was also conducted along with additional clinical follow up as indicated.
RESULTS: A total of 375 inguinal hernia repairs were performed during the study period. Of these, 354 laparoscopic inguinal hernia repairs were performed on 242 patients. Two hundred ninety one primary repairs and 63 recurrent repairs were included. No significant intraoperative complications occurred. Median follow up was 30 months (95% confidence interval, 28-34). Only 22 patients (9%) were lost to follow up. Seventy percent of patients responded to contact for long term follow up with a telephone survey. Immediate post operative complications included 9 hematomas (3.7%), 18 seromas (7.4%), 5 wound infections (2.1%), and 6 patients (2.5%) with urinary retention. A total of 23 patients (9.5%) had post operative pain that did not resolve by the time of initial follow up. Follow up telephone surveys using a validated pain questionnaire showed 15 patients (6.2%) with current chronic pain. None have required time off of their occupation or long term pain medications for their chronic pain. Two recurrences (0.57%) developed over the follow up period. When these complication rates were compared between the two surgeons, no significant differences were found. Additionally, comparison of the first half of each surgeons’ experience with the later half showed no significant differences except for hematoma rate for one surgeon, which was higher during his initial experience (6 vs 0, rr= 0.94, p < 0.03).
CONCLUSION: The learning curve for laparoscopic inguinal hernia repair can be eliminated by MIS fellowship training. Surgeons who complete a MIS fellowship which includes experience in laparoscopic inguinal hernia repair can perform the procedure with outcomes comparable to more experienced surgeons who have not had formal training. Laparoscopic inguinal hernia repair performed by well trained surgeons should be considered a good option for all types of groin hernias.