Publication:

A study of the learning curve of total extraperitoneal repair of inguinal hernia among young laparoscopic surgeons in a tertiary care centre in an urban city

Background Totally extraperitoneal (TEP) repair of inguinal hernia is a technically demanding laparoscopic procedure with a well-recognized steep learning curve. Limited data exist from teaching institutions in developing countries regarding the progression of surgical competence among young laparoscopic surgeons.

Methods A prospective observational study was conducted over two years in the Department of General Surgery at a tertiary care teaching hospital. Twenty-five young laparoscopic surgeons with 1–5 years of laparoscopic experience were enrolled. Data on operative time, intraoperative complications, need for senior assistance, mesh fixation method, and surgeon confidence were collected sequentially for each TEP procedure performed. Surgeons were categorized into early (≤10 cases) and late (>10 cases) learning phases. Statistical analysis was performed using Student's t-test, Mann–Whitney U test, Chi-square, and Fisher's exact test as appropriate.

Results The majority of surgeons were aged 30–35 years (44%), with 36% having 1–2 years of laparoscopic experience. Mean operative time decreased significantly from 142±28 minutes in the early phase to 78±18 minutes in the late phase (p<0.001). Requirement for senior assistance decreased from 68% to 22% (p=0.002), and mean confidence score improved from 2.8±0.9 to 4.1±0.7 (p<0.001). A statistically significant association was found between number of TEP procedures performed and operative time reduction (p=0.003). Creation of the space of Bogros (24%) and dissection of Cooper's ligament (16%) were identified as the most time-consuming and assistance-requiring steps.

Conclusions TEP repair has a clearly defined and significant learning curve. Proficiency is progressively achieved with increasing case volume, with substantial improvement observable beyond 10 cases in this cohort. Structured mentorship, targeted training on critical dissection steps, and adequate case exposure are essential for safe and efficient skill acquisition.