Standardization and learning curve in laparoscopic hernia repair: experience of a high-volume center

Abstract

Purpose: Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons.

Methods: The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors' experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed.

Results: The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia.

Conclusions: The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency.

Keywords: Critical view of safety; Groin hernia; Inguinal hernia; Laparoscopy; Mesh; TAPP; Transabdominal preperitoneal.

Fig. 1

(a): Revised anatomical landmarks: P2 stands for the second triangle of pain. It covers the varying anatomy of nerve branches and the transversus abdominis muscle area. (b): Revised division and numbering of the posterior inguinal region

Fig. 2

(a): Trocars placement for unilateral right hernia. (b): Trocars placement for bilateral hernia defects

Fig. 3

(a): Peritoneal flap opening 4 cm above the inguinal ring, slightly lateral to the pathway of epigastric vessels. (b): The peritoneal incision allows carbon dioxide diffusion in the preperitoneal space carrying out a pneumo dissection

Fig. 4

(a): We suggest for a peritoneal incision not exceeding 6–8 cm. (b): The epigastric vessels are the first anatomical landmark. It is advisable to identify these vessels before dissecting into zone 1

Fig. 5

(a): Detachment of the direct hernia sac from the pseudosac. The direct defect is located superolaterally to the Cooper’s ligament. (b): Cooper’s ligament dissection: the second anatomical landmark. The vessel slightly above the ligament belongs to Corona mortis. In this area we suggest performing preventive coagulation

Fig. 6

(a): Commencement of the hernia sac reduction procedure into the abdominal cavity. Due diligence must be exercised to carefully monitor the vas deferens course during this critical stage. (b): The hernia sac is almost completely reduced into the abdomen and the elements of the spermatic cord are completely isolated and detached from the hernia sac. It is possible to observe the cleavage plane (green line) between the sac and the elements that will lead to complete reduction

Fig. 7

The result obtained after the complete parietalization of the vas deferens and the spermatic vessels

Fig. 8

(a): In the case of large direct inguinal hernias, we recommend suturing the defect while paying attention to the elements of the spermatic cord that run below the defect. (b): The result obtained after the defect closure.

Fig. 9

(a): Polypropylene 3D mesh placed: a curved, three-dimensional, pre-shaped prosthesis. (b): The image shows the closed peritoneum. We suggest using the redundant direct hernia sac, when present, to reinforce the suture