REVIEW ARTICLE
Laparoscopic Ventral Hernia Repair: Defining the Learning Curve Arwa Al-Harazi, MD, Rajat Goel, MS, DNB, Charles T.K. Tan, MD, Wei Keat Cheah, MD, and Davide Lomanto, MD
Abstract: Between 2004 and June 2011, 181 patients underwent laparoscopic ventral hernia repair. Three main surgeons, all experienced in laparoscopic procedures, performed all the cases. After analyzing the operative time (OT) for 3 main surgeons, within the first 20 cases the overall performance plateaued. Data from 60 patients (50F, 10M), with a mean age of 42.3 years (range, 26 to 88 y) and a mean hernia defect size of 6.5 cm (range, 4 to 18 y), were evaluated. No significant differences were recorded among the 3 surgeons in OT and intraoperative or postoperative complications. But 3 (5%, P < 0.03) patients had complications, and the recurrence rate was 6.6% with a mean follow-up of 54 months (range, 42 to 70 mo). One had prolonged postoperative ileus, the second had bowel serosal tear, and the last had port-site incarcerated hernia. Our results showed that the OT of 98.9 minutes (range, 48 to 205 min) stabilized in 12 cases. Key Words: laparoscopy, ventral hernia, learning curve, surgery
(Surg Laparosc Endosc Percutan Tech 2014;24:475–477)
I
ncisional hernias are acquired ventral hernias (VH) with well-documented risk factors.1 VH is still a frequent complication after laparotomy with the incidence ranging between 3% and 13% in various series.2–5 The repair of VH has undergone a paradigm shift, from primary suture repairs with high recurrence rates (12% to 54%),6–8 to open mesh repairs with recurrence rates between 2% to 36%,9–11 to the first successful laparoscopic VH repair (LVHR) in 1993, by LeBlanc and Booth,12 and successful reports of the advantage of laparoscopic repairs over open hernia repairs in terms of complications and recurrence rates.2,13,14 LVHR is based on the tenets of the open Rives-Stoppa repair and on the Pascal Principle of hydrostatics such that the forces that cause hernia are currently used to hold the mesh in place, thus decreasing the chance of recurrence and offering the potential benefits of minimally invasive surgery: smaller scars, less postoperative pain, shorter hospital stay, fewer infectious complications, and less overall cost.13–15 Every surgery has its own learning curve; the aim of our article is to define the learning curve for LVHR.
Received for publication May 30, 2013; accepted September 30, 2013. From the Department of Surgery, Minimally Invasive Surgical Centre, National University Hospital, Singapore, Singapore. The authors declare no conflicts of interest. Reprints: Rajat Goel, MD, MBBS, MS, DNB, Department of Surgery, Minimally Invasive Surgical Centre, Yong Loo Lin School of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, 119074 Singapore, Singapore (e-mail: goelrajat27@gmail. com) Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
MATERIALS AND METHODS We retrospectively collected data for patients who underwent LVHR between 2004 and June 2011. Patient demographics (sex, age, type of hernia, previous repair), operative findings [operative time (OT), size of defect, mesh used, conversion rates], any intraoperative or postoperative complications, length of hospital stay, and recurrence rates in follow-up were calculated and analyzed. The patients were followed up at 1 week and 1, 3, 6, and 12 months after surgery and yearly thereafter. All patients were operated by 3 surgeons well experienced in laparoscopic surgery. The results were analyzed using SPSS software. Informed consent was taken in all patients and both laparoscopic and open repair techniques were likewise discussed as surgical options, and only patients who preferred the laparoscopic approach were included in this series. Patients with intra-abdominal sepsis, peritonitis, and infection were excluded. Abdominal computed tomography scan and bowel preparation were performed only in patients with nonreducible or recurrent hernia. Preoperative prophylactic antibiotics using firstgeneration cephalosporin were given 1 hour before the procedure. Antiembolic stockings were used routinely.
Surgical Technique The standardized surgical technique as described below2 was used in all patients by all the 3 surgeons. All patients were in the supine position and were administered general anesthesia. Pneumoperitoneum was established either by the open abdominal access technique or by using an optical trocar in patients with a body mass index >27. The first trocar was inserted in the right or left flank, depending on the hernia location and far from the defect. A 30-degree scope was used in all the procedures. Two additional 5 mm trocars were inserted on both sides of the optical trocar under direct vision. If needed, an additional trocar (5 or 10 mm) was inserted to facilitate mesh fixation on the opposite side. After an initial exploration of the whole abdominal cavity, adhesiolysis was performed with sharp dissection using laparoscopic scissors and, in difficult cases, using alternative energy sources like diathermy, Harmonic scalpel (Ethicon), or Ligasure (Covidien). The intraperitoneal onlay mesh technique was used in all cases. An antiadhesive mesh was rolled and inserted through the 12 mm port and accurately positioned to overlap the edges of the defect by at least 3 to 5 cm all over with the antiadhesive surface facing the bowel. Nonabsorbable sutures were secured to the 4 cardinal points of the mesh to anchor it transfascially. The mesh was further fixed using a nonabsorbable fixation device (Protack; Covidien) in a double crown technique. Peritoneum and fascial closure for the 12 mm port was performed. The skin was closed with absorbable sutures. Compressive pressure bandage dressing
Volume 24, Number 6, December 2014
www.surgical-laparoscopy.com |
475
Surg Laparosc Endosc Percutan Tech
Al-Harazi et al
TABLE 1. Patient Demographics and Operative Data
Parameter
Total Number n = 181
Final Number Evaluated n = 60
P
Mean age (y) 53.1 (26-88) 42.3 (26-88) NS* Sex 141F, 40M 50F, 10M NS Type of hernia 164P, 17R 53P, 7R NS (primary/ recurrent) Mean defect size 6.8 ± 4.6 (2.7–24) 6.5 ± 4.3z (4-18) NS (range) (cm) Conversion to 4 (2.2) 2 (3.3) NS open [n (%)] Mean operating 121.5 ± 79.3 114 ± 53.4z NS time (min) Intraoperative 8 (4.4) 3 (5) P < 0.03w complications [n (%)] Mean hospital 4.5 ± 10.5 3.7 ± 4.6 NS stay (d) Mean VAS 4.6 (2-6) 4.8 (2-7) NS score 48 h (range) Recurrences [n 8 (4.4) 4 (6.6) NS (%)] *P-value not significant. wP-value significant (< 0.05). zThe correlation between hernia defect size and OT is mild (r = 0.181, P = 0.015). NS indicates not significant; VAS, visual analog scale.
was then applied for at least 5 days, followed by use of an abdominal binder for 1 month, to reduce the “dead space” and possibly the seroma formation.
RESULTS A total of 181 (141F; 40M) patients underwent LVHR by 3 surgeons. On analyzing the OT time for each of them, we noticed that within the first 20 cases a plateau was achieved. So finally 60 patients (50F; 10M) with a mean age of 42.3 (range, 26 to 88 y) were analyzed. The patient demographics and operative data are summarized in Table 1. When we compared the first 20 patients of each surgeon (n = 60) with the total number, we found that there was no statistical difference in patient demographics
Volume 24, Number 6, December 2014
and operative data, except there was a significant higher complication rate in the first 20 patients (P < 0.03). Three (5%) of the first 20 patients developed complications, with 1 having prolonged postoperative ileus, the second having bowel serosal tear, and the last having port-site hernia incarceration. No conversion to open repair was recorded in all 3 groups. The main late complications are recurrence, and we had 8 (4.4%) recurrences overall and 4 (6.6%) recurrences in first 60 cases. To assess the learning curve, the OT was evaluated for each surgeon and plotted on a graphical scale. In our study, 12 cases seem to be necessary to achieve a plateau in the LVHR performance and a comparable clinical outcome (Fig. 1). There was a mild correlation between size of hernia defect and OT (r = 0.181, P = 0.015).
DISCUSSION There are numerous reports in the literature to suggest LVHR to be safe and effective alternative to open VH repair and some reports even suggest fewer complications and recurrence rates.2,13–15 LVHR like any other minimally invasive procedure also offers advantages of smaller scars, less postoperative pain, shorter hospital stay, fewer infectious complications, and less overall cost in various studies.13–15 LVHR has its own challenges: challenges of any other minimally invasive procedure, familiarity of new instruments (meshes, tackers, suture passers, etc), and familiarity of laparoscopic anatomy (although minimal for an experienced laparoscopic surgeon). The exact definition of learning curve in laparoscopic procedures is unclear. The possible factors that may influence the learning curve can be: surgeon’s experience with other laparoscopic procedures and instrumentation, knowledge of laparoscopic anatomy, standardization of surgical technique, frequency of procedure, supporting staff, stabilization of OT, and complication rate. In our series, all procedures were performed by 3 experienced laparoscopic surgeons well experienced with other advanced laparoscopic procedures and instrumentation; all 3 surgeons followed the same standardized technique. All 3 surgeons performed on an average 3 to 4 cases per month in the initial 20 cases, although they started at different time periods, at the same hospital with assistance from similar support staff. It has to be emphasized that experienced laparoscopic surgeons as in our study can draw from their previous experiences and benefit from mastered laparoscopic skills when attempting a new procedure. The
FIGURE 1. The learning curve graph for laparoscopic ventral hernia repair for the 3 surgeons. LVH indicates laparoscopic ventral hernia; OT, operating time.
476 | www.surgical-laparoscopy.com
r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 6, December 2014
average OT stabilized for all 3 surgeons in the first 20 cases, and when we plotted the average OT time, we found the first flat line at 12 cases. There were 3 complications in our series in the first 20 cases each; 1 patient who had prolonged postoperative ileus due to longer OT recovered on conservative management. Prolonged postoperative ileus can be prevented using a standardized surgical technique so that the procedure can be performed faster, avoiding unnecessary handling of the bowel and complete suction of blood clots if any. The second patient developed a serosal tear, which was sutured intraperitoneally. Serosal tear can be prevented in irreducible hernias by dissecting on the neck of the sac on the abdominal wall surface rather than on the body; minimal serosal tears can be left as it is but major serosal tears need laparoscopic or open suturing. The last patient developed port-site hernia incarceration, requiring relaparoscopy for management. Port-site incarcerated hernias are a surgical emergency, for which relaparoscopy and reduction of hernia contents (generally omentum) suffice. Port-site hernias can be prevented by closing 10 to 12 mm ports carefully with absorbable sutures, avoiding unnecessary suction while deflating the abdomen. Suture passers and port closure needles can also be used for successful port closure. There are few reports defining the learning curve in laparoscopic total extraperitoneal repair in various series between 60 and 100 cases.16–17 To the best of our knowledge, there is no study on the learning curve for LVHR. In our series the OT stabilized at around 12 cases.
Limitations Our study has its limitations. All LVHRs were performed by experienced laparoscopic surgeons in our series, thus a learning curve of 12 cases may not reflect the true learning curve for a new laparoscopic surgeon. There was no mention of postoperative seroma in the records for all the patients, and hence it could not be compared.
CONCLUSIONS In our study, the learning curve for LVHR is 12 cases. An experienced laparoscopic surgeon shifting to LVHR has a short learning curve with acceptable conversion, complication, and recurrence rates. The presence of an experienced laparoscopic surgeon would help prevent complications in the early learning period and would help reduce the OT.
r
2014 Lippincott Williams & Wilkins
LVHR Learning Curve
REFERENCES 1. Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg. 2000;24:95–101. 2. Lomanto S, Iyer G, Shabbir A, et al. Laparoscopic versus open ventral hernia mesh repair: a prospective study. Surg Endosc. 2006;20:1030–1035. 3. Mudge M, Hughes LE. Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J Surg. 1985;72:70–71. 4. Lewis RT, Wiegand FM. Natural history of vertical abdominal parietal closure: prolene versus dexon. Can J Surg. 1989; 32:196–200. 5. Hoer J, Lawong G, Klinge U. Factors influencing the development of incisional hernia: a retrospective study of 2983 laparotomy patients over a period of 10 years. Chirurg. 2002;73:474–480. 6. Manninen MJ, Lavonius M, Perhoniemi VJ, et al. Results of incisional hernia repair: a retrospective study of 172 unselected hernioplasties. Eur J Surg. 1991;157:29–31. 7. Anthony T, Bergen PC, Kim LT. Factors affecting recurrence following incisional herniorrhaphy. World J Surg. 2000;24: 95–1000. 8. Luijendijk RW, Hop WC, van den Tol MP. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392–398. 9. van der Linden FT, van Vroonhoven TJ. Long term results after surgical correction of incisional hernia. Neth J Surg. 1998;40:127–129. 10. Liakakos T, Karanikas I, Panagiotidis H. Use of marlex mesh in the repair of recurrent incisional hernia. Br J Surg. 1994;81:248–249. 11. Toniato A, Pagetta C, Bernante P. Incisional hernia treatment with progressive pneumoperitoneum and retromuscular prosthetic herniplast. Lagenbecks Arch Surg. 2000;387:246–248. 12. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc. 1993;3:39–41. 13. Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral hernia repair. J Laparoendosc Adv Surg Tech A. 2000; 10:79–84. 14. Misra MC, Bansal VK, Kulkarni MP, et al. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006;20:1839–1845. 15. Sajid MS, Bokhari SA, Mallick AS, et al. Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009;197:64–72. 16. Lau H, Patil NG, Yuen WK, et al. Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Surg Endosc. 2002;16:1724–1728. 17. Choi YY, Kim Z, Hur KY. Learning curve for laparoscopic totally extraperitoneal repair of inguinal hernia. Can J Surg. 2012;55:33–36.
www.surgical-laparoscopy.com |
477
Laparoscopic Ventral Hernia Repair: Defining the Learning Curve Arwa Al-Harazi, MD, Rajat Goel, MS, DNB, Charles T.K. Tan, MD, Wei Keat Cheah, MD, and Davide Lomanto, MD
Abstract: Between 2004 and June 2011, 181 patients underwent laparoscopic ventral hernia repair. Three main surgeons, all experienced in laparoscopic procedures, performed all the cases. After analyzing the operative time (OT) for 3 main surgeons, within the first 20 cases the overall performance plateaued. Data from 60 patients (50F, 10M), with a mean age of 42.3 years (range, 26 to 88 y) and a mean hernia defect size of 6.5 cm (range, 4 to 18 y), were evaluated. No significant differences were recorded among the 3 surgeons in OT and intraoperative or postoperative complications. But 3 (5%, P < 0.03) patients had complications, and the recurrence rate was 6.6% with a mean follow-up of 54 months (range, 42 to 70 mo). One had prolonged postoperative ileus, the second had bowel serosal tear, and the last had port-site incarcerated hernia. Our results showed that the OT of 98.9 minutes (range, 48 to 205 min) stabilized in 12 cases. Key Words: laparoscopy, ventral hernia, learning curve, surgery
(Surg Laparosc Endosc Percutan Tech 2014;24:475–477)
I
ncisional hernias are acquired ventral hernias (VH) with well-documented risk factors.1 VH is still a frequent complication after laparotomy with the incidence ranging between 3% and 13% in various series.2–5 The repair of VH has undergone a paradigm shift, from primary suture repairs with high recurrence rates (12% to 54%),6–8 to open mesh repairs with recurrence rates between 2% to 36%,9–11 to the first successful laparoscopic VH repair (LVHR) in 1993, by LeBlanc and Booth,12 and successful reports of the advantage of laparoscopic repairs over open hernia repairs in terms of complications and recurrence rates.2,13,14 LVHR is based on the tenets of the open Rives-Stoppa repair and on the Pascal Principle of hydrostatics such that the forces that cause hernia are currently used to hold the mesh in place, thus decreasing the chance of recurrence and offering the potential benefits of minimally invasive surgery: smaller scars, less postoperative pain, shorter hospital stay, fewer infectious complications, and less overall cost.13–15 Every surgery has its own learning curve; the aim of our article is to define the learning curve for LVHR.
Received for publication May 30, 2013; accepted September 30, 2013. From the Department of Surgery, Minimally Invasive Surgical Centre, National University Hospital, Singapore, Singapore. The authors declare no conflicts of interest. Reprints: Rajat Goel, MD, MBBS, MS, DNB, Department of Surgery, Minimally Invasive Surgical Centre, Yong Loo Lin School of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, 119074 Singapore, Singapore (e-mail: goelrajat27@gmail. com) Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
MATERIALS AND METHODS We retrospectively collected data for patients who underwent LVHR between 2004 and June 2011. Patient demographics (sex, age, type of hernia, previous repair), operative findings [operative time (OT), size of defect, mesh used, conversion rates], any intraoperative or postoperative complications, length of hospital stay, and recurrence rates in follow-up were calculated and analyzed. The patients were followed up at 1 week and 1, 3, 6, and 12 months after surgery and yearly thereafter. All patients were operated by 3 surgeons well experienced in laparoscopic surgery. The results were analyzed using SPSS software. Informed consent was taken in all patients and both laparoscopic and open repair techniques were likewise discussed as surgical options, and only patients who preferred the laparoscopic approach were included in this series. Patients with intra-abdominal sepsis, peritonitis, and infection were excluded. Abdominal computed tomography scan and bowel preparation were performed only in patients with nonreducible or recurrent hernia. Preoperative prophylactic antibiotics using firstgeneration cephalosporin were given 1 hour before the procedure. Antiembolic stockings were used routinely.
Surgical Technique The standardized surgical technique as described below2 was used in all patients by all the 3 surgeons. All patients were in the supine position and were administered general anesthesia. Pneumoperitoneum was established either by the open abdominal access technique or by using an optical trocar in patients with a body mass index >27. The first trocar was inserted in the right or left flank, depending on the hernia location and far from the defect. A 30-degree scope was used in all the procedures. Two additional 5 mm trocars were inserted on both sides of the optical trocar under direct vision. If needed, an additional trocar (5 or 10 mm) was inserted to facilitate mesh fixation on the opposite side. After an initial exploration of the whole abdominal cavity, adhesiolysis was performed with sharp dissection using laparoscopic scissors and, in difficult cases, using alternative energy sources like diathermy, Harmonic scalpel (Ethicon), or Ligasure (Covidien). The intraperitoneal onlay mesh technique was used in all cases. An antiadhesive mesh was rolled and inserted through the 12 mm port and accurately positioned to overlap the edges of the defect by at least 3 to 5 cm all over with the antiadhesive surface facing the bowel. Nonabsorbable sutures were secured to the 4 cardinal points of the mesh to anchor it transfascially. The mesh was further fixed using a nonabsorbable fixation device (Protack; Covidien) in a double crown technique. Peritoneum and fascial closure for the 12 mm port was performed. The skin was closed with absorbable sutures. Compressive pressure bandage dressing
Volume 24, Number 6, December 2014
www.surgical-laparoscopy.com |
475
Surg Laparosc Endosc Percutan Tech
Al-Harazi et al
TABLE 1. Patient Demographics and Operative Data
Parameter
Total Number n = 181
Final Number Evaluated n = 60
P
Mean age (y) 53.1 (26-88) 42.3 (26-88) NS* Sex 141F, 40M 50F, 10M NS Type of hernia 164P, 17R 53P, 7R NS (primary/ recurrent) Mean defect size 6.8 ± 4.6 (2.7–24) 6.5 ± 4.3z (4-18) NS (range) (cm) Conversion to 4 (2.2) 2 (3.3) NS open [n (%)] Mean operating 121.5 ± 79.3 114 ± 53.4z NS time (min) Intraoperative 8 (4.4) 3 (5) P < 0.03w complications [n (%)] Mean hospital 4.5 ± 10.5 3.7 ± 4.6 NS stay (d) Mean VAS 4.6 (2-6) 4.8 (2-7) NS score 48 h (range) Recurrences [n 8 (4.4) 4 (6.6) NS (%)] *P-value not significant. wP-value significant (< 0.05). zThe correlation between hernia defect size and OT is mild (r = 0.181, P = 0.015). NS indicates not significant; VAS, visual analog scale.
was then applied for at least 5 days, followed by use of an abdominal binder for 1 month, to reduce the “dead space” and possibly the seroma formation.
RESULTS A total of 181 (141F; 40M) patients underwent LVHR by 3 surgeons. On analyzing the OT time for each of them, we noticed that within the first 20 cases a plateau was achieved. So finally 60 patients (50F; 10M) with a mean age of 42.3 (range, 26 to 88 y) were analyzed. The patient demographics and operative data are summarized in Table 1. When we compared the first 20 patients of each surgeon (n = 60) with the total number, we found that there was no statistical difference in patient demographics
Volume 24, Number 6, December 2014
and operative data, except there was a significant higher complication rate in the first 20 patients (P < 0.03). Three (5%) of the first 20 patients developed complications, with 1 having prolonged postoperative ileus, the second having bowel serosal tear, and the last having port-site hernia incarceration. No conversion to open repair was recorded in all 3 groups. The main late complications are recurrence, and we had 8 (4.4%) recurrences overall and 4 (6.6%) recurrences in first 60 cases. To assess the learning curve, the OT was evaluated for each surgeon and plotted on a graphical scale. In our study, 12 cases seem to be necessary to achieve a plateau in the LVHR performance and a comparable clinical outcome (Fig. 1). There was a mild correlation between size of hernia defect and OT (r = 0.181, P = 0.015).
DISCUSSION There are numerous reports in the literature to suggest LVHR to be safe and effective alternative to open VH repair and some reports even suggest fewer complications and recurrence rates.2,13–15 LVHR like any other minimally invasive procedure also offers advantages of smaller scars, less postoperative pain, shorter hospital stay, fewer infectious complications, and less overall cost in various studies.13–15 LVHR has its own challenges: challenges of any other minimally invasive procedure, familiarity of new instruments (meshes, tackers, suture passers, etc), and familiarity of laparoscopic anatomy (although minimal for an experienced laparoscopic surgeon). The exact definition of learning curve in laparoscopic procedures is unclear. The possible factors that may influence the learning curve can be: surgeon’s experience with other laparoscopic procedures and instrumentation, knowledge of laparoscopic anatomy, standardization of surgical technique, frequency of procedure, supporting staff, stabilization of OT, and complication rate. In our series, all procedures were performed by 3 experienced laparoscopic surgeons well experienced with other advanced laparoscopic procedures and instrumentation; all 3 surgeons followed the same standardized technique. All 3 surgeons performed on an average 3 to 4 cases per month in the initial 20 cases, although they started at different time periods, at the same hospital with assistance from similar support staff. It has to be emphasized that experienced laparoscopic surgeons as in our study can draw from their previous experiences and benefit from mastered laparoscopic skills when attempting a new procedure. The
FIGURE 1. The learning curve graph for laparoscopic ventral hernia repair for the 3 surgeons. LVH indicates laparoscopic ventral hernia; OT, operating time.
476 | www.surgical-laparoscopy.com
r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 6, December 2014
average OT stabilized for all 3 surgeons in the first 20 cases, and when we plotted the average OT time, we found the first flat line at 12 cases. There were 3 complications in our series in the first 20 cases each; 1 patient who had prolonged postoperative ileus due to longer OT recovered on conservative management. Prolonged postoperative ileus can be prevented using a standardized surgical technique so that the procedure can be performed faster, avoiding unnecessary handling of the bowel and complete suction of blood clots if any. The second patient developed a serosal tear, which was sutured intraperitoneally. Serosal tear can be prevented in irreducible hernias by dissecting on the neck of the sac on the abdominal wall surface rather than on the body; minimal serosal tears can be left as it is but major serosal tears need laparoscopic or open suturing. The last patient developed port-site hernia incarceration, requiring relaparoscopy for management. Port-site incarcerated hernias are a surgical emergency, for which relaparoscopy and reduction of hernia contents (generally omentum) suffice. Port-site hernias can be prevented by closing 10 to 12 mm ports carefully with absorbable sutures, avoiding unnecessary suction while deflating the abdomen. Suture passers and port closure needles can also be used for successful port closure. There are few reports defining the learning curve in laparoscopic total extraperitoneal repair in various series between 60 and 100 cases.16–17 To the best of our knowledge, there is no study on the learning curve for LVHR. In our series the OT stabilized at around 12 cases.
Limitations Our study has its limitations. All LVHRs were performed by experienced laparoscopic surgeons in our series, thus a learning curve of 12 cases may not reflect the true learning curve for a new laparoscopic surgeon. There was no mention of postoperative seroma in the records for all the patients, and hence it could not be compared.
CONCLUSIONS In our study, the learning curve for LVHR is 12 cases. An experienced laparoscopic surgeon shifting to LVHR has a short learning curve with acceptable conversion, complication, and recurrence rates. The presence of an experienced laparoscopic surgeon would help prevent complications in the early learning period and would help reduce the OT.
r
2014 Lippincott Williams & Wilkins
LVHR Learning Curve
REFERENCES 1. Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg. 2000;24:95–101. 2. Lomanto S, Iyer G, Shabbir A, et al. Laparoscopic versus open ventral hernia mesh repair: a prospective study. Surg Endosc. 2006;20:1030–1035. 3. Mudge M, Hughes LE. Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J Surg. 1985;72:70–71. 4. Lewis RT, Wiegand FM. Natural history of vertical abdominal parietal closure: prolene versus dexon. Can J Surg. 1989; 32:196–200. 5. Hoer J, Lawong G, Klinge U. Factors influencing the development of incisional hernia: a retrospective study of 2983 laparotomy patients over a period of 10 years. Chirurg. 2002;73:474–480. 6. Manninen MJ, Lavonius M, Perhoniemi VJ, et al. Results of incisional hernia repair: a retrospective study of 172 unselected hernioplasties. Eur J Surg. 1991;157:29–31. 7. Anthony T, Bergen PC, Kim LT. Factors affecting recurrence following incisional herniorrhaphy. World J Surg. 2000;24: 95–1000. 8. Luijendijk RW, Hop WC, van den Tol MP. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392–398. 9. van der Linden FT, van Vroonhoven TJ. Long term results after surgical correction of incisional hernia. Neth J Surg. 1998;40:127–129. 10. Liakakos T, Karanikas I, Panagiotidis H. Use of marlex mesh in the repair of recurrent incisional hernia. Br J Surg. 1994;81:248–249. 11. Toniato A, Pagetta C, Bernante P. Incisional hernia treatment with progressive pneumoperitoneum and retromuscular prosthetic herniplast. Lagenbecks Arch Surg. 2000;387:246–248. 12. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc. 1993;3:39–41. 13. Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral hernia repair. J Laparoendosc Adv Surg Tech A. 2000; 10:79–84. 14. Misra MC, Bansal VK, Kulkarni MP, et al. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006;20:1839–1845. 15. Sajid MS, Bokhari SA, Mallick AS, et al. Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009;197:64–72. 16. Lau H, Patil NG, Yuen WK, et al. Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Surg Endosc. 2002;16:1724–1728. 17. Choi YY, Kim Z, Hur KY. Learning curve for laparoscopic totally extraperitoneal repair of inguinal hernia. Can J Surg. 2012;55:33–36.
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