Beyond the five triangles: anatomical mastery, technique standardization, and skills development as the triad for excellence in robotic inguinal hernia repair

The integration of robotic platforms into general surgery continues to accelerate, and nowhere is this transformation more evident than in inguinal hernia repair. The robotic approach has emerged as a credible and increasingly preferred alternative to conventional laparoscopy, offering enhanced three-dimensional visualization, tremor filtration, and wristed instrumentation that significantly expand the technical envelope of minimally invasive groin surgery. These advantages are particularly meaningful in complex scenarios—bilateral hernias, recurrent defects, obese patients, and cases requiring precise intracorporeal suturing for peritoneal closure—where laparoscopic ergonomics have historically imposed real limitations. Against this backdrop, the video vignette and accompanying article by Butnari et al., entitled Robotic Transabdominal Pre-Peritoneal Repair of a Bilateral Inguinal Hernia: A Surgical Technique Displaying an Educational Roadmap Using Furtado’s 5 Triangles Concept, published in this paper, represent a timely and technically rigorous contribution to the robotic inguinal hernia literature (1).

The authors present an 82-year-old female who underwent robotic transabdominal pre-peritoneal (rTAPP) repair of bilateral inguinal hernias using a well-structured technique anchored in Furtado’s inverted Y and five triangles conceptual framework. What distinguishes this work is not merely the procedural account, but rather the deliberate educational architecture built around it: the real-time digital overlay of anatomical landmarks onto the live robotic field, transforming the video into a structured teaching tool that bridges the gap between posterior groin anatomy as described on a diagram and as encountered intraoperatively. The clarity with which the five triangles are demonstrated in the video—identifying the safety zones, danger zones, and critical neurovascular structures of the myopectineal orifice (MPO)—is commendable and will undoubtedly serve as a valuable reference for surgeons at various stages of their training.

We would like to offer several complementary perspectives that we believe further enrich the educational framework proposed by the authors.

First, from a didactic standpoint, Furtado’s five triangles provide an essential anatomical scaffold, but they are perhaps most powerful when integrated with a systematic technical protocol. In this regard, the ten golden rules for safe minimally invasive inguinal hernia repair described by Claus, Furtado, Malcher, and colleagues represent a critical complement to the anatomical framework (2). These rules, built upon the dual foundation of the critical view of the MPO and the inverted Y/five triangles model, translate anatomical knowledge into a stepwise intraoperative discipline applicable across transabdominal pre-peritoneal (TAPP), totally extraperitoneal (TEP), extended totally extraperitoneal (eTEP), and rTAPP approaches. Rules governing the extent of medial dissection, the mandatory identification of Cooper’s ligament before mesh placement, the management of lipomas at the internal ring, and the closure of the peritoneal flap with suture rather than tackers are not merely technical preferences—they are evidence-anchored standards that reduce variability and protect against the most common causes of recurrence and nerve injury. When teaching rTAPP, pairing the five triangles visualization with explicit adherence to these ten rules creates a more complete and reproducible educational roadmap than anatomical orientation alone.

Second, it is worth emphasizing that the technical complexity of rTAPP is highly variable, ranging from straightforward primary repairs to challenging cases involving prior pelvic surgery, large defects, or significant preperitoneal fat. Safe and consistent performance across this spectrum demands genuine technical proficiency built through structured, deliberate practice outside the operating room. In this regard, virtual reality platforms address basic console psychomotor skills, but validated synthetic tissue models are indispensable as training advances toward full procedural simulation. We have recently validated a synthetic hydrogel model for robotic TAPP repair through an international expert panel, supporting its integration into structured robotic training curricula (3). The deliberate cultivation of technical skills through such validated tools is, alongside anatomical knowledge and technique standardization, an essential pillar of surgical excellence in this field.

In summary, optimal outcomes in robotic inguinal hernia repair rest on a triad (Table 1): thorough mastery of posterior groin anatomy through frameworks such as Furtado’s five triangles; systematic adherence to evidence-based technical standards such as the ten golden rules; and the deliberate cultivation of technical skills through validated simulation outside the operating room. Butnari and colleagues have made a meaningful contribution to the first pillar of this triad. We congratulate the authors on an excellent video and manuscript that will undoubtedly enhance anatomical understanding and surgical training for the growing community of surgeons embracing the robotic platform for groin hernia repair.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article did not undergo external peer review.

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-2026-0041/coif). A.S. is a consultant for IMRA Surgical. The other 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.

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/.

References

1. Butnari V, Nambiar P, Mansuri A, et al. Robotic transabdominal pre-peritoneal repair of a bilateral inguinal hernia: a surgical technique displaying an educational roadmap using Furtado's 5 triangles concept. J Vis Surg 2026;12:14. [Crossref] [PubMed]
2. Claus C, Furtado M, Malcher F, et al. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surg Endosc 2020;34:1458-64. [Crossref] [PubMed]
3. Sanchez A, Rodriguez O, Takla H, et al. Robot-assisted TAPP inguinal hernia repair training: validation of a synthetic hydrogel model-an international expert panel study. J Robot Surg 2026;20:493. [Crossref] [PubMed]