Laparoscopic Inguinal Hernioplasty (TAPP) Performed by Residents Under Supervision: An Observational Study in a University HospitalABSTRACT
Introduction: Transabdominal Preperitoneal (TAPP) laparoscopic repair of groin hernias has demonstrated high success rates with a reduced risk of postoperative complications. However, achieving optimal outcomes requires dedicated training for surgical residents. This study aimed to evaluate the safety of laparoscopic inguinal hernioplasty using the TAPP technique when performed by general surgery residents under supervision at a university hospital, and to describe patient characteristics and postoperative complications.
Method: This was an observational, retrospective, and descriptive study of patients who underwent laparoscopic inguinocrural hernioplasty using the TAPP technique performed by general surgery residents at Presidente Dutra University Hospital between 2017 and 2022.
Results: A total of 77 patients were included; 84.4% were male, and 58.44% reported symptom duration of up to two years. Postoperative complications were observed in 31.17% of cases: 3.9% developed surgical site infection at the umbilical port; 2.6% had hematoma; 12.99% developed scrotal seroma; 14.29% reported chronic pain; and 2.6% experienced hernia recurrence. Complications were classified as Clavien-Dindo27 (CD) IIIA in 11.69% and CD II in 12.99% of patients. All patients who reported severe pain at late postoperative follow-up progressed to chronic pain (p < 0.001), as did 90% of those with complications classified as CD II. Most patients who developed a seroma had a disease duration of more than three years.
Conclusion: Laparoscopic inguinal hernioplasty using the TAPP technique, when performed by residents under supervision, demonstrated an acceptable safety profile, with most complications being low grade, supporting the feasibility of incorporating this procedure into surgical training programs.
Keywords:
Laparoscopic Inguinal Hernia; Medical Internship and Residency; Postoperative Complications; Laparoscopy, Performance
RESUMO
Introdução: O reparo laparoscópico transabdominal pré-peritoneal (TAPP) das hérnias de virilha tem demonstrado alto índice de sucesso com reduzido risco de complicações pós-operatórias. Porém, sua realização exige treinamento específico dos residentes em busca de melhores resultados. Objetiva-se avaliar a segurança da hernioplastia inguinal laparoscópica pela técnica TAPP realizada por residentes de cirurgia geral sob supervisão em hospital universitário, descrevendo o perfil clínico dos pacientes e as complicações pós-operatórias.
Metodologia: Tratou-se de um estudo observacional, retrospectivo e descritivo dos pacientes submetidos à hernioplastia inguinocrural pela técnica TAPP realizada por residentes de cirurgia geral do Hospital Universitário Presidente Dutra entre 2017 e 2022.
Resultados: Dos 77 pacientes, 84,4% eram do sexo masculino e 58,44% relataram um período de doença de até 2 anos. Houve complicações pós-operatórias em 31,17% das cirurgias: 3,9% com infecção de sítio cirúrgico em região umbilical; 2,6% com hematoma; 12,99% com seroma em região escrotal; 14,29% com dor crônica e 2,6% desenvolveram recidiva herniária. Entre as complicações, 11,69% foram classificadas como Clavien Dindo27 (CD) IIIA e 12,99% como CD II. A evolução para dor crônica ocorreu em todos os pacientes que relataram dor intensa no pós-operatório tardio (p < 0,001) e em 90% dos pacientes com complicações classificadas como Clavien-Dindo II. A maioria dos pacientes que apresentaram seroma possuíam tempo de doença superior a 3 anos.
Conclusão: A hernioplastia inguinal laparoscópica pela técnica TAPP realizada por residentes sob supervisão demonstrou perfil de segurança aceitável, com predominância de complicações de baixa gravidade, reforçando a viabilidade do procedimento no contexto de formação cirúrgica.
Palavras-chave:
Hérnia inguinal laparoscópica; Internato e Residência; Complicações Pós-Operatórias; Laparoscopia; Performance
INTRODUCTION
Inguinal hernias account for approximately 75% of all abdominal wall hernias1 and represent a significant public health issue due to the high annual surgical volume and their impact on quality of life2. The condition predominantly affects men, with a higher incidence among older individuals and frequent association with comorbidities3.
An estimated 20 million inguinal hernia repairs are performed worldwide each year4, including primary, recurrent, and bilateral cases. This substantial surgical volume highlights the importance of proper technical training during general surgery residency5,6, particularly given the expanding role of minimally invasive techniques in contemporary practice7.
Inguinal hernia repair can be performed using open, laparoscopic, or robotic approaches, with technique selection tailored to patient characteristics and surgeon expertise8. Among open techniques, the Lichtenstein repair remains widely used9 and is still considered the gold standard in many institutions10. However, it has been associated with higher rates of chronic postoperative pain compared with minimally invasive approaches11.
Laparoscopic techniques offer several advantages, including lower rates of surgical site infection, reduced chronic pain, and faster return to normal activities12. The main laparoscopic approaches include Totally Extraperitoneal (TEP) repair and Transabdominal Preperitoneal (TAPP) repair13. The TAPP technique is based on the dissection of the preperitoneal space, reduction of the hernia contents, placement of a polypropylene mesh, followed by peritoneal closure2,14.
The incorporation of minimally invasive surgery into the treatment of abdominal wall diseases has also significantly modified the teaching-learning process in general surgery, requiring structured and progressive technical training15,16. In this context, laparoscopic inguinal hernia repair presents a relatively long learning curve, related to the need for detailed anatomical knowledge and development of advanced laparoscopic skills17. Traditionally, the learning curve has been assessed using indirect performance measures such as operative time and procedural volume18,19,20.
Despite the widespread use of TAPP inguinal hernioplasty, data on outcomes in the context of surgical training at Brazilian university hospitals remain limited, particularly given the clinical and educational realities of these institutions. At the Hospital Universitário da Universidade Federal do Maranhão (HU-UFMA), TAPP repair is performed by general surgery residents under the direct supervision of attending surgeons as part of their laparoscopic training.
In this setting, systematic analysis of clinical and operative outcomes is relevant for understanding the results achieved in this training environment, taking into account the structural and care-related characteristics of a public teaching hospital. Nevertheless, findings should be interpreted within the institutional context and not extrapolated as broad causal conclusions.
This study aimed to characterize the epidemiological profile of patients undergoing laparoscopic inguinal hernioplasty using the TAPP technique and to assess the safety of procedures performed by supervised general surgery residents at a university hospital, with a focus on postoperative complications and clinical outcomes.
METHODS
Study Design
This retrospective, observational, descriptive study was based on a review of electronic medical records of patients who underwent laparoscopic inguinal hernia repair using the TAPP technique. Procedures were performed by second- and third-year residents in the General Surgery Residency Program at the Hospital Universitário da Universidade Federal do Maranhão (HU-UFMA), under direct attending supervision.
Population and Inclusion/Exclusion Criteria
All patients who underwent laparoscopic inguinal hernia repair (TAPP) between January 2017 and September 2022, corresponding to the implementation period of the technique at the institution, were eligible.
Initially, 98 patients were identified. Twelve cases operated on by other surgical teams, three duplicate records, two cases converted to open technique, and one patient lost to follow-up were excluded. The final sample consisted of 77 patients.
The sample included all consecutive eligible cases during the study period, constituting a convenience sample, without prior sample size calculation due to the institutional descriptive design.
Surgical Technique
The procedure followed the standardized TAPP technique21,22. Patients were positioned supine under general anesthesia. Pneumoperitoneum was established using the Veress needle or Hasson technique, with intra-abdominal pressure maintained between 10 and 15 mmHg. Three trocars were used: one periumbilical (10 mm) for the optical port and two lateral ports (10 mm on the right and 5 mm on the left).
Systematic dissection of the preperitoneal space was performed22, including reduction of the hernia sac and assessment for spermatic cord lipoma. A monofilament polypropylene mesh measuring at least 15 × 10 cm was used, with or without fixation (suture or surgical adhesive)23, at the discretion of the responsible surgeon24. The peritoneum was closed with a continuous suture, and the pneumoperitoneum was released under direct visualization25,26.
author’s archive: zones of the inguinal region after dissection and reduction of the hernia sac.
Resident Supervision
Second- and third-year general surgery residents performed all procedures under the direct supervision of attending surgeons experienced in laparoscopic surgery.
Residents had prior average experience in basic laparoscopic procedures (cholecystectomy and appendectomy) before performing the TAPP technique. The attending surgeon provided continuous supervision throughout all procedural stages, including technical guidance, intraoperative correction, and decision-making regarding necessary interventions when indicated.
Variables analyzed
Sociodemographic (sex, age, origin, occupation), clinical (comorbidities, body mass index, smoking status, social alcohol use), and surgical data were collected.
Preoperative variables included American Society of Anesthesiologists (ASA)27 classification, Nyhus classification28, Caprini score29 for thromboembolic risk, and Apfel score30 for postoperative nausea and vomiting.
Operative variables included operative time, mesh fixation type, surgical conversion, and length of hospital stay31.
Postoperative outcomes assessed were urinary retention, surgical site infection, hematoma, seroma, immediate postoperative pain, late pain, chronic pain (defined as duration greater than three months)32, and recurrence33. Only symptomatic events were considered complications, according to international guidelines34.
The minimum follow-up period was three months.
Statistical Analysis
Data were organized in an electronic database and analyzed using Stata software (version 12.0).
Descriptive analysis was initially performed using absolute and relative frequencies, measures of central tendency (mean or median), and measures of dispersion (standard deviation or interquartile range), with interval estimates (95% confidence interval).
The sample was divided into two groups based on the presence or absence of postoperative complications, enabling comparative analysis between groups.
Given the retrospective design and convenience sampling, no prior statistical power calculation was performed. Analyses should be interpreted as exploratory.
Inferential analyses were employed in a complementary and exclusively exploratory manner, and the results should be interpreted with caution, given the inherent limitations of the retrospective design and institutional convenience sampling.
Descriptive analyses of the main variables were prioritized, avoiding multiple secondary comparisons that could lead to unsupported inferences. Results are presented in tables and graphs. The significance level adopted was 5%.
Ethical aspects
As a retrospective, observational, and descriptive study based on anonymized secondary data, the Research Ethics Committee waived the requirement for informed consent in accordance with National Health Council Resolution No. 466/2012.
To ensure confidentiality and participant privacy, data were tabulated in an electronic spreadsheet (Microsoft Excel 2013), in which each patient was identified only by a numeric code. Access to the database was restricted to researchers through password protection.
Regarding procedural safety, all clinical procedures analyzed were performed by credentialed attending surgeons with extensive technical and academic experience during residency training. The study was conducted in strict compliance with ethical standards and approved by the HU-UFMA Research Ethics Committee (CAAE: 64862222.2.0000.5086).
RESULTS
Seventy-seven patients who underwent laparoscopic inguinocrural hernioplasty using the Transabdominal Preperitoneal (TAPP) technique between 2017 and 2022 were included.
Demographic and Clinical Characteristics of the Sample
Male patients were predominant (84.42%). The most frequent age group was 51-60 years (27.27%), followed by 61-70 years (24.68%).
Regarding comorbidities, 48.05% of patients had no associated diseases, with systemic arterial hypertension being the most prevalent condition (29.87%).
In terms of body mass index, 42.86% had a BMI between 18.5 and 24.9 kg/m², while 25.97% had a BMI between 25 and 29.9 kg/m².
Regarding occupational profile, 50.65% performed activities requiring minimal physical exertion, whereas 35.06% engaged in activities associated with increased intra-abdominal pressure (Table 1).
Descriptive characteristics of patients undergoing inguinocrural hernia repair using the TAPP technique from 2017 to 2022 (N = 77).
Characteristics of the Hernia Disease
Right-sided inguinal hernia was most prevalent (57.14%), followed by left-sided inguinal hernia (33.77%). Bilateral inguinal hernia was observed in 6.49% of patients, and right femoral hernia in 2.60%.
According to the Nyhus classification, the most frequent types were type II (33.77%), type IIIa (25.97%), and type IVa (18.18%).
Disease duration was less than two years in 58.44% of patients, with the one- to two-year interval being most common (38.96%) (Table 2).
Characteristics of hernia disease in patients undergoing inguinocrural hernia repair using the TAPP technique from 2017 to 2022 (N = 77).
Operative Data
Operative time showed wide variability across procedures. The highest frequency of surgeries occurred in the 3:01-3:30 hour interval (27.27%), followed by 2:31-3h (19.48%) and 3:31-4h (16.88%) (Table 2).
Postoperative Complications
Most patients did not experience postoperative complications (68.83%; n = 53). Complications occurred in 24 patients (31.17%).
According to the Clavien-Dindo35 classification, five patients (6.49%) had grade I complications, ten (12.99%) grade II, and nine (11.69%) grade IIIa.
Among complications, seroma was the most frequent, identified in 60% of patients with grade I complications and 77.78% of those classified as grade IIIa.
Surgical site infection was observed in 20% of grade I patients, 10% of grade II patients, and 11.11% of grade IIIa patients.
Hematoma was observed exclusively among grade IIIa patients (22.22% of this group) (Table 3).
Seroma incidence was associated with longer disease duration, being more frequent in patients with disease duration exceeding three years (Graph 1).
Comparison Between Patients With and Without Complications
For comparative purposes, patients were divided into two groups based on the presence of postoperative complications.
The group without complications comprised 53 patients (68.83%), while the group with complications included 24 patients (31.17%).
Among patients without complications, most did not report pain during late postoperative follow-up (83.02%), whereas 15.09% reported mild pain and 1.89% moderate pain.
In the group with complications, a higher frequency of postoperative pain was observed, particularly among patients classified as Clavien-Dindo II, in whom 90% presented moderate pain at late follow-up.
Among patients classified as Clavien-Dindo IIIa, 55.56% reported mild pain and 11.11% moderate pain (Table 3).
DISCUSSION
This study evaluated outcomes of laparoscopic inguinal hernioplasty using the Transabdominal Preperitoneal (TAPP) technique performed by supervised general surgery residents in a university hospital. Complication, recurrence, and surgical site infection rates were comparable to those described in the literature,36 although with longer operative time.37 Although the overall complication rate was 31.17%, most events were of low severity, predominantly self-limited seromas classified as Clavien-Dindo I or II. These findings suggest that the technique can be safely performed in a training setting, provided that it is supervised by experienced surgeons.
The overall complication rate was similar to that reported in clinical series of laparoscopic hernioplasty, in which seroma and postoperative pain are among the most frequently described events. The surgical site infection rate also remained within limits reported in previous studies, which generally describe an incidence below 5% in laparoscopic procedures. These findings reinforce the benefits of the minimally invasive approach, associated with less tissue manipulation and reduced wound exposure.
The recurrence rate was low and consistent with results reported in multicenter studies and systematic reviews of the TAPP technique. Hernia recurrence is considered a key quality outcome in abdominal wall surgery and is often related to technical factors, surgical team experience, and characteristics of the hernia disease. In the present study, even with resident participation during the learning curve, recurrence rates remained within acceptable limits reported in the literature.
Regarding postoperative pain, a relatively higher incidence of chronic pain was observed compared to some contemporary series.38 Chronic pain following hernioplasty is a multifactorial phenomenon and may be associated with technical factors, nerve handling, mesh fixation methods, and individual patient characteristics39. Within a surgical training context, the greater tissue manipulation inherent in the learning curve may contribute to an increased incidence of this outcome. However, this relationship has not been fully established.
The operative time was longer than that reported in specialized high-volume centers. This finding likely reflects the training environment and active participation of residents early in their learning curve, which is inherent to academic hospitals. Previous studies demonstrate that the learning curve for laparoscopic hernioplasty may require dozens of procedures to consolidate the necessary skills, directly impacting operative duration4. Nevertheless, several authors demonstrate that resident participation, when appropriately supervised, does not significantly compromise procedural safety40.
In this context, the results reinforce the importance of direct supervision by experienced surgeons during laparoscopic procedures within residency training programs. The presence of an attending surgeon allows immediate correction of technical difficulties and enhances patient safety throughout the training process. University hospitals, therefore, play a fundamental role in preparing surgeons capable of safely performing minimally invasive procedures.
Some limitations must be considered in interpreting these results. The retrospective design limits control over confounding variables and depends on the accuracy of medical record documentation. Additionally, the number of patients included was relatively small, and there was no comparison group, such as procedures performed exclusively by experienced surgeons or via open technique. Finally, the convenience sample from a single center limits generalizability to other practice settings.
CONCLUSION
In the analyzed context, laparoscopic inguinal hernioplasty using the TAPP technique, performed by supervised residents, demonstrated an acceptable safety profile, with complication and recurrence rates comparable to those reported in the literature, supporting its feasibility in a surgical training environment. However, findings should be interpreted with caution due to the retrospective design, institutional sample, and absence of a comparison group.
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