We performed a retrospective review of all patients who underwent laparoscopic TEP herniorrhaphy by a single surgeon consecutively at a single center from September 2008 to Jan 2020. This study includes the operator's first TEP herniorrhaphy case. Although this surgeon has 15 years of experience in upper gastrointestinal surgery, he has no experience in laparoscopic hernia surgery other than an open hernia. Prior to initiating TEP herniorrhaphy surgery, operators participated in animal surgery experiments and live surgery lectures. The clinical features, operating time, operative findings, and outcomes were reviewed in the medical records. To investigate the recurrence and reoperation rate, the patients were followed up by telephone or physical examination.
A total of 291 patients underwent laparoscopic TEP herniorrhaphy. Every operation was a scheduled operation. Patients with an inguinal hernia who underwent another surgical procedure at the same time were excluded. Finally, 257 patients were analyzed. We calculated how many surgeries were needed to achieve a reduction in the expected operating time to mean operating time ratio.
A logarithmic function and an exponential function were derived from the operating time data by univariate cox regression analysis and graphs were generated. The number of surgeries was plotted along the X-axis and the operating time was plotted along the Y-axis (Figs. 1 and 2). Then, we calculated how many surgeries were needed to achieve a reduction in the expected operating time to mean operating time ratio (Figs. 1 and 2). Statistical analysis was performed using SPSS version 23.0.
Surgical technique
The surgical technique methods was performed identically to that used in our previous learning curve studies(22). The patients were asked to empty their bladder before surgery. Under general anesthesia, all patients were placed in the supine position. The operator and the first assistant stood at the opposite side of the lesion. The main role of the first assistant was as the scopist.
One 10-mm trocar and two 5-mm trocars were used. The 10-mm trocar was placed through the supraumbilical incision and one 5-mm trocar was placed at the suprapubic area and the other 5-mm trocar was placed between the two of them.
A 10-mm balloon trocar was proceeded along the anterior side of the posterior rectus sheath beyond the arcuate line. After inflating the balloon catheter, Cooper’s ligament, the inferior epigastric vessel, and the hernia sac could be identified.
the case of an indirect inguinal hernia, a hernia sac presents at the lateral side of the inferior epigastric vessel. Dissection of the medial side precedes dissection of the lateral side. Dissection of the lateral side starts from the lateral side of the inferior epigastric vessel and attempts to secure the pre-peritoneal space.
The next step was the dissection of the spermatic cord and should be done carefully because, in an indirect hernia, the hernia sac is encapsulated with the spermatic cord. In the case of a direct hernia, the hernia sac usually is separated and reduced by inflation of the balloon trocar. In this case, the pseudo sac was fixed to Cooper’s ligament to distinguish it from relapse after surgery.
After reducing the hernia sac, an artificial mesh (Parietex, 15x10 cm, Sofradium) was inserted between the abdominal wall and the peritoneum. The most important thing in this procedure is peritonization of the hernia sac and parietalization of the spermatic cord.
The medial margin of the mesh was fixed on Cooper’s ligament with a tack. After thrombin spraying and deflation with the observation that the inserted mesh was in the proper position, the operation was completed.