Robotic transabdominal pre-peritoneal repair of a bilateral inguinal hernia: a surgical technique displaying an educational roadmap using Furtado’s 5 triangles concept

Introduction

Inguinal or groin hernias are a very common condition in the UK population, mainly affecting men (1). This condition involves protrusion of the abdominal contents through a weak point in the groin. While some inguinal hernias are asymptomatic, others cause pain and discomfort that necessitates surgical repair to improve quality of life and prevent incarceration and obstruction (2,3). The vast majority of groin hernias are inguinal accounting for 96%. These can be bilateral in up to 20% of affected adults. The remaining 4 percent are femoral and obturator being the rarest one (4,5).

Operations to repair groin hernias are one of the most frequent performed procedures done around the world (1). Open repair, specifically Lichtenstein repair, is a well-established surgical technique for treating unilateral inguinal hernias (6,7). Over the years surgical methods for hernia repair have evolved progressing from open to less invasive minimal access techniques, and most recently to robotic assisted procedures. These minimally invasive techniques utilise smaller skin incisions resulting with less postoperative pain and quicker return to daily activities making possible simultaneous bilateral repair if needed (8).

Despite being a common procedure, hernia repair is not free of complications. A solid understanding of surgical anatomy of the myopectineal orifice (MPO), is essential for a successful outcome (9,10). This anatomical area has been described by Dr. Henry Fruchaud in 1956. Situated in the lower part of abdominal wall, this represents a weak area where all types of groin hernias appear. The medial border of this is represented by rectus abdominis muscle; inferiorly this is marked by the pectineal ligament, laterally by psoas muscle and superiorly by transversus abdominis and internal oblique muscles.

The internal landmarks of MPO are best understood through the conceptual framework of the inverted Y or 5 triangles described by Furtado et al. (11). This model provides a didactic way to visualise the MPO and also facilitates deeper anatomical understanding of inguinocrural region and various hernia defects that may occur. In addition, from identification of all key structures it’s possible to establish a technical systematization for dissection of posterior inguinal region and consequent repair. Daes et al. described the critical view of safety in laparoscopic inguinal hernia repair recently in analogy to the concept used to reliably perform a laparoscopic cholecystectomy (12). While this framework is applicable to laparoscopy, the robotic platform enhances their implementation through stable three-dimensional (3D) magnified visualisation, enabling more precise and reproducible identification and dissection of myopectineal landmarks.

The increased popularity of robotic platforms within surgical units around the world has significantly advanced minimally invasive general surgery, with the robotic groin hernia repair emerging as safe and feasible alternative to already established laparoscopic techniques (13,14).

While direct comparative data for rTAPP and robotic totally extraperitoneal (rTEP) repairs remains limited, insights can be drawn from established laparoscopic benchmarks. Current systematic reviews indicate comparable outcomes regarding postoperative recurrence and chronic pain, providing a robust evidentiary foundation for further evaluation of their clinical efficacy (15).

Within this report (Video S1) we present an anatomical demonstration of MPO based on Furtado et al. classification together with detailed video of a robotic repair performed at Barking, Havering and Redbridge University Hospitals NHS Trust (11). We present this article in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-35/rc) (16).

Preoperative preparations and requirements

All procedures performed in this video vignette were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Setting

This procedure was performed within Elective Hub based within King Georges Hospital part of Barking, Havering and Redbridge University Hospitals NHS Trust. Our surgical elective hub is recognized as one of the pioneering eight institutions in the country to receive accreditation from the Getting It Right First-Time initiative within the national scheme. Within general surgery department there are 2 Da Vinci Xi robotic surgical platforms and 7 robotic surgeons who passed their learning curve. The robotic team includes the surgeon, anesthetist, anesthetic nurse, scrub nurse and robotic assistant.

Patient presentation and preoperative assessment

The patient was an 82-year-old female, with a World Health Organization (WHO) performance status of zero. Her only comorbidity was hiatus hernia and Rockwood Frailty Score of 2. She was referred by her general practitioner with a painful reducible lump in her groin, which was positive for cough impulse and was suggestive of inguinal hernia. A computed tomography (CT) scan of the abdomen and pelvis revealed a right inguinal hernia (Figure 1). However, as the clinical examination suggested a bilateral issue and the patient reported persistent pain, subsequently surgical intervention was offered. In the clinical decision-making process, chronological age was not considered a limiting factor for offering minimally invasive approach. Rather, a holistic assessment was performed, taking into account the patient’s low frailty score and minimal comorbidities as a complete clinical picture. Based on EHS Guidelines, endoscopic management is nominated as preferred for primary bilateral inguinal hernias (17). The rTAPP approach was selected as a safe and effective alternative to conventional laparoscopy as demonstrated by several systematic reviews and meta-analyses and availability of the robotic platform (18,19). This decision was further supported by the desire for a rapid recovery and minimal postoperative pain, which are significant factors in functional independence postoperatively in the patients above 70 years of age. The choice of the robotic platform over traditional laparoscopy was driven by the need to mitigate technical challenges of laparoscopy. While laparoscopic TAPP offers significant benefits, its adoption is often restricted by a steep learning curve and difficulties with intracorporeal suturing (20). The robotic system overcomes these hurdles by providing wristed instrumentation and a stable 3D magnified view. Routine blood investigations and preoperative optimisation was done. Prior to commencing a minimally invasive hernia repair we usually place a urinary catheter which is taken out at the end of the procedure. In low-risk patients for both minimally invasive and open hernia repair procedures we do not administer prophylactic antibiotics as per EHS Guidelines (17). The patient is initially placed in supine position. Intraoperatively, after pneumoperitoneum is successfully achieved and ports are inserted under direct vision, using integrated table motion patient is placed into a Trendelenburg position (up to 15 degrees head down) with side inclination with contralateral tilt to the hernia defect (up to 10 degrees). Patient is positioned on an anti-slip mat and straps are used.

Figure 1 Computed tomography scan of the patient’s abdomen and pelvis with yellow arrow indicating the right-sided inguinal hernia.

Step-by-step description

After the surgical WHO timeout performed, procedure commenced with the achievement of the pneumoperitoneum using Veress needle insufflation at the supraumbilical midline (Video S1). This corresponds to the insertion site of one of the 8-mm ports. Working distance between the ports is usually 6 to 8 cm depending on the body habitus of the patient. The target point corresponding to pubic symphysis is measured maximum distance of 20 cm. After appropriate insufflation is achieved and port sites are marked, a 12-mm visiport was inserted in the right pararectal space followed by the placements of two 8-mm robotic ports, which were placed under direct vision in a straight line above umbilicus (Figure 2). To optimise operative efficiency, we usually introduce the mesh and sutures for peritoneal closure through the 12-mm port at the outset of the procedure. The robotic ports configuration is depicted in Figure 2. This comprises a 12-mm port (utilising a reducer) for the monopolar scissors, an 8-mm midline camera port and an 8-mm port in the left mesogastrium for the bipolar grasper. While the distance between robotic ports is usually 6–8 cm depending on the patient’s body habitus, in this case, a 7-cm interval was maintained between each port. We prefer introducing a 12-mm port off centre due to the “sandwich effect”. As usually this port goes through the rectus abdominis when the port is removed, the muscle fibres naturally approximate reducing the risk of postoperative hernia. Diagnostic laparoscopy revealed bilateral inguinal hernias. We began at first with the right-side dissection.

Figure 2 Port positioning.

As displayed in our video (Video S1) in our routine practice, starting point of pre-peritoneal dissection is approximately 2–3 cm superior to anterior-superior iliac spine. The incision is then extended in the sigmoid fashion towards the medial umbilical ligament. Following the peritoneal incision, we proceed with the medial dissection towards the prevesical space or also known as cave of Retzius. The objective is to clearly establish the junction between the anterior and posterior layers of fascia transversalis. This is achieved by maintaining proximity to the peritoneum during dissection and carefully pushing the peritoneal fatty tissue superiorly. We dissect the areolar tissues until we identify pubic bone and Cooper’s ligament.

On the right sided the dissection revealed that the hernia was located laterally to the inferior epigastric vessels and superior to ileo-pubic tract consistent with an indirect inguinal hernia. Following the completion of the medial dissection (Zone 2), we transition our focus to the space of Bogros (Zone 1). The enhanced dexterity and magnified vision offered by the robotic platform coupled up with the precise control of the grasper and scissors facilitate a safe and thorough lateral dissection of MPO.

Once the sac is mobilised 360 degrees and delineated from the surrounding structures, we look for any associated lipoma, which may be respected. Lipomas are found within the internal inguinal ring, protruding through the defect alongside (or lateral to) the hernia sac. Even if no indirect sac is found during initial diagnostic laparoscopy, the surgeon must mobilize the pre-peritoneal fat to ensure no lipoma is tucked into the canal. Reduction of the lipoma is the preferred method and can be done using blunt dissection and traction-countertraction manoeuvres away from inguinal canal structures. However, when lipomas are massive or so bulky that it would prevent the mesh from lying flat against abdominal wall then preferred method world be resection using monopolar or bipolar energy available during the procedure.

The management of the distal sac varies from one case to another. For smaller indirect hernias, the entire sac can be dissected out and reduced, whereas for larger hernias, the sac can be transected, leaving the distal portion in place. Only when the inguinal canal structures are identified and safeguarded, we can proceed to division of the sac. Further during our dissection, we identified both femoral and obturator hernias containing pre peritoneal fat, they were also reduced.

A similar dissection was then performed on the left side. Once the dissection of both sides was done prosthetic mesh is put into place. We used anatomical 15 cm × 10 cm pre-shaped self-gripping meshes, which were carefully adjusted and positioned within both right and left inguinal regions.

The anatomically pre-shaped, side-specific mesh is designed to provide coverage of the MPO, addressing direct, indirect, femoral, and obturator defects. During placement, precise positioning is critical: the mesh must cross the midline medially by 1–2 cm, extend laterally to the anterior superior iliac spine, and reach at least 3 cm superior to the upper border of the hernia defect. Inferiorly, the mesh must lie flat to ensure complete coverage of both the femoral and obturator spaces. Subsequently, the peritoneal flaps were then closed using absorbable self-locking 3/0 Filbloc^® sutures, ensuring a secure mesh placement and preventing visceral herniation. The suturing is performed in the lateral to medial fashion.

Postoperative considerations and tasks

The total operative time was 80 minutes. The Foley’s catheter was removed after the procedure in the operating theatre. Usually, once the operation is done, our patients go from the operating room to the recovery room, where they spend a couple of hours being closely monitored. Subsequently, if their vital signs are satisfactory, they are transferred to the day surgery unit. All patients must go to the toilet independently and pass urine and tolerate a light meal before they are discharged. We routinely use absorbable suture material for the wounds which is followed up in the community. The patient had an uneventful recovery and was discharged home on the same day. In the majority of our cases, incisions are secured with an air- and watertight dressing in the form of skin glue. Patients are explicitly advised not to peel the adhesive layer away. However, they may shower the day following the procedure, provided they avoid scrubbing the incision sites directly. To minimise the risk of recurrence and ensure adequate fascial healing, patients are instructed to avoid lifting objects heavier than 15–20 pounds (approximately 10 kg) for a minimum of two weeks post-surgery.

The return to driving is contingent upon functional recovery rather than a fixed timeline. Specifically, patients must be able to perform an emergency stop comfortably and without pain. For most patients, this threshold is reached between one and two weeks postoperatively. Our follow-up occurs within three months of the procedure, typically conducted via a telephone clinic. They are encouraged to present to the outpatient clinic should they have any concerns regarding wound healing, pain, or other postoperative issues. Before discharge patients are provided with contact details of surgical team secretaries in order to initiate patient initiate follow up if they wish to be consulted earlier.

Tips and pearls

The successful execution of a rTAPP inguinal repair hinges on preoperative planning with appropriate imaging, seamless robotic team coordination, and a profound mastery of the robotic platform. Centrally, the efficacy of the rTAPP approach relies on exploiting the platform’s high-definition visualisation and articulated dexterity to achieve a definitive “critical view” of the MPO. Surgeons should utilise this enhanced precision to perform skeletonisation of the inguinal canal structures, clearly delineating Cooper’s ligament and the iliopubic tract. This allows for the atraumatic reduction of the hernia sac while simultaneously safeguarding the delicate structures of the inguinal canal. Furthermore, a significant technical advantage of the robotic approach is the total elimination of traumatic tackers. The platform’s wristed instrumentation facilitates continuous suturing of the peritoneal flap, which is particularly beneficial in morbidly obese patients where traditional laparoscopy is often ergonomically restrictive. By opting for sutured closure rather than mechanical fixation, the surgeon significantly mitigates the risk of nerve entrapment and subsequent chronic inguinodynia.

Discussion

Robotic assisted surgery is certainly a revolutionising field in medicine with remarkable innovations and trends across all surgical specialties. This approach was initially established in urology before being then rapidly adopted by general surgery for a wide range of procedures including groin hernia repair. This is largely due to robotic platform’s ability to provide operating surgeon with enhanced 3D vision and dexterity which results with higher precision during groin dissection and more delicate tissue handling. These advantages are instrumental in reducing tissue trauma and subsequently minimising the risk of postoperative pain, a common concern of established methods in hernia repair. Particularly the feature of robotic platform enables safe and more precise parietalisation of the cord structures which is one of the most important parts of the operation in male cases. After creation of a wide peritoneal flap, the indirect sac is placed under traction and sharp dissection is carried out in the avascular plane between the peritoneum and the cord, staying directly on the sac to avoid injury to the vas and pampiniform plexus. Adequate parietalisation is confirmed when the mesh can be placed flat without tenting; incomplete dissection is a known cause of lateral recurrence.

The robotic TAPP repair is evolving technique with operative times comparable with conventional methods in units where it is routinely performed (21). While the current advantages are still debated due to a lack of randomised evidence, the overall shift towards robotic approach aims to improve patient’s outcomes and short-term recovery as reported in some series (15,17).

This procedure is the ideal starting point for surgeons seeking to gain proficiency with robotic platform, as it allows for repetitive practice of essential skills such as docking, dissection, mesh handling and suturing of the peritoneal flap (20). Although robot offers clear ergonomic advantage for the operating surgeon, the widespread adoption of this technique worldwide is limited by the high cost of consumables and the need for specialised training (22,23). A study using cumulative sum analysis reported that surgeons already experienced in laparoscopic hernia repair reached approximately 43 rTAPP cases to achieve 90% proficiency, shown by significant reduction in operative time and fewer complications (23). It is important to acknowledge that currently the reported data show minimal differences in postoperative outcomes when comparing robotic with laparoscopic approaches. In part this is mainly because authors are frequently non-specific about the complexity of the reported procedures such as whether they are bilateral, recurrent or emergent hernias.

Beyond the approach used for this procedure the efficiency and successful outcomes of the repair are directly linked to the surgeon’s anatomical knowledge of the internal view of the MPO, which subsequently impacts outcomes (24,25).

Initially reported data on laparoscopy when transitioning from open approach suggested longer operative times and higher costs. As surgeons progressed through their learning curves and got familiar with the method these disadvantages were overcome, and the benefits of new method became more apparent. In similar fashion, the advantages of robotic surgery including shorter times and improved outcomes are likely to be realised as surgeons and robotic teams gain experience through hand-on practice. While initial big investment in platform acquisition, consumables and training is notable the potential advantages are significant. As more surgeons become proficient with the robotic platform, its role as a valuable and effective tool in modern surgery will be established and reinforced.

Conclusions

Our article serves as a guide for rTAPP repair, highlighting its potential as a training tool for surgeons embarking on minimally invasive groin hernia surgery. By providing a reproducible framework for dissection, the five-triangles concept establishes rigorous anatomical limits that reduce procedural variability and effectively compensate for the lack of tactile feedback inherent to the robotic platform. Adherence to these boundaries, specifically the skeletonization of Cooper’s ligament, the iliopubic tract and inguinal canal structures minimises technical errors and complications by providing consistent anatomical exposure for standardised mesh positioning.

This structured approach, encompassing an understanding of the MPO, is particularly valuable during the learning curve to mitigate risks of neurovascular injury and hernia recurrence. Ultimately, while this step-by-step guide aims to enhance surgical training and the informed consent process, further randomised controlled trials comparing robotic and laparoscopic approaches are essential to fully define the role of the robotic platform in the surgical treatment of inguinal hernias.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-35/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-35/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-35/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this video vignette were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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