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Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression

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Abstract

Background

Laparoscopic inguinal hernia repair has a long learning curve. It can be a technically challenging procedure and initially presents an unfamiliar view of inguinal anatomy. The aim of this review was to evaluate published literature relating to the learning curve of laparoscopic inguinal hernia repair and identify the number of cases required for proficiency. The secondary aim was to compare outcomes between surgeons before and after this learning curve threshold had been attained.

Methods

A systematic literature search was conducted in databases of PubMed, Medline, Embase, Web of Science, and Cochrane Library, to identify studies that evaluated the learning curve of laparoscopic inguinal hernia repair. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon’s learning phase and experienced phase of the curve.

Results

Twenty-two studies were included in this review, with 19 studies included in the meta-regression analysis, and 11 studies included in the meta-analysis. Mixed-effects Poisson regression demonstrated that there was a non-linear trend in the number of cases required to achieve surgical proficiency, with a 2.7% year-on-year decrease. The predicted number of cases to achieve surgical proficiency in 2020 was 32.5 (p < 0.01). The meta-analysis determined that surgeons in their learning phase may experience a higher rate of conversions to open (OR 4.43, 95% CI 1.65, 11.88), postoperative complications (OR 1.61, 95% CI 1.07, 2.42), and recurrences (OR 1.32, 95% CI 0.40, 4.30).

Conclusion

Laparoscopic inguinal hernia repair has a well-defined learning curve. While learning surgeons demonstrated reasonable outcomes, supervision during this period may be appropriate given the increased risk of conversion to open surgery. These data may benefit learning surgeons in the skill development of minimally invasive inguinal hernia repairs.

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Funding

This research was supported by the 2022 Research Grant from the Epworth Medical Foundation (Grant Number: 82093). No other financial assistance was sought for this research.

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Authors and Affiliations

  1. Clinical Institute General Surgery and Gastroenterology, Epworth Healthcare, Richmond, Australia

    Jonathan Sivakumar, Michael W. Hii, Mark Cullinan, Julian Choi, Mark Steven & Gary Crosthwaite

  2. Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia

    Jonathan Sivakumar

  3. Department of Surgery, The University of Melbourne, Melbourne, Australia

    Jonathan Sivakumar, Michael W. Hii & Gary Crosthwaite

  4. Department of Upper Gastrointestinal Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Australia

    Qianyu Chen & Michael W. Hii

  5. Department of Surgery, Monash University, Clayton, VIC, Australia

    Mark Cullinan

  6. Department of Upper Gastrointestinal and Hepatobiliary Surgery, Western Health, Melbourne, Australia

    Julian Choi

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Supplementary file3 (DOCX 24 KB) Summary of outcomes in laparoscopic inguinal hernia repair performed by learning versus experienced surgeons (Certainty of evidence assessment outlined)

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Sivakumar, J., Chen, Q., Hii, M.W. et al. Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression. Surg Endosc 37, 2453–2475 (2023). https://doi.org/10.1007/s00464-022-09760-3

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