Laparoscopic inguinal hernia repair (LIHR) by early-career surgeons (ECSs) in a tertiary centre at Southern Malaysia: outcomes of a structured training module

Introduction

Laparoscopic inguinal hernia repair (LIHR) has been commonly performed for more than a decade. However, it is a less commonly applied surgical approach by the early-career surgeons (ECSs) in Malaysia compared to the conventional open repair. There was evidence suggesting an upward trend in the practice of laparoscopic repair due to quicker recovery and reduced post-operative pain (1,2). However, there remained a paucity in literature regarding the volume of laparoscopic hernia repair performed in Malaysia. In the new era of precision surgery, it is paramount to provide patients with the option of minimally invasive surgery (MIS) for hernia repair in sustainable future (1,3). Based on a study in a tertiary referral centre in India, the learning curves of both transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) were similar, and 13–15 cases were required initially to ensure competency (4). In our center, a structured training module was established to support ECSs in safely transitioning to independent performance of LIHR. Hence, this paper aimed to describe the outcomes of a series of 42 patients that underwent LIHR performed by ECSs after completion of the training module. We present this article in accordance with STROBE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-35/rc).

Methods

Study design

This was a retrospective cohort study that included all cases of LIHRs performed by 5 ECSs who had successfully completed a standardised training module. The study period spanned from February 2022 to May 2023, and all 42 cases were retrieved from the surgical registry of Hospital Sultanah Aminah Johor Bahru (HSAJB). ECSs were defined as surgeons with 1–3 years practicing of post-qualification experience, all of whom had assisted in ≥5 LIHR cases prior to training. There was a total of 42 eligible cases retrieved from the surgical registry of HSAJB. All patients were reviewed at 1, 2, and 3 months for their post-operative conditions. No patients were lost to follow-up (Figure 1).

Figure 1 Flow diagram illustrating the structure of the study. Five ECSs who completed a standardized training module performed a total of 42 LIHR. Cases were categorized as either supervised (n=14) or independent (n=28) based on the level of intraoperative oversight. Outcomes assessed at 1-, 2-, and 3-month post-operation included pain (measured using VAS), recurrence, and postoperative complications. ECSs, early-career surgeons; LIHR, laparoscopic inguinal hernia repairs; VAS, Visual Analogue Scale.

Supervised procedures were performed with the proctor scrubbed in. Independent procedures were done with the proctor on standby outside the sterile field.

Patient selection was not random; instead, all patients were carefully assessed and selected preoperatively by the treating ECSs in accordance with predefined institutional criteria to ensure case suitability for ECSs. These criteria included: age ≥18 years, reducible hernia, no major comorbidities, and hernia defect size ≤7 cm as assessed intraoperatively. Patients with American Society of Anaesthesiologists (ASA) classification ≥ III or uncontrolled chronic illness were excluded. The largest diameter of hernia defect, as assessed intraoperatively, was ≤7 cm, per institutional protocol to ensure case appropriateness for ECSs. Patients with complicated hernias (e.g., obstruction, strangulation, or irreducibility) or those unfit for general anaesthesia were excluded. This approach ensured that all included patients shared comparable baseline characteristics, thereby enhancing the consistency and applicability of the training outcomes being assessed.

Both TAPP and TEP approaches were included in this study, as ECSs were trained in both techniques during the structured training module. The choice of TAPP vs. TEP was made based on surgeon preference and patient suitability rather than a predefined allocation. TEP was the preferred approach for primary cases with small, reducible hernias, in accordance with institutional practice. TAPP was selected when intra-abdominal inspection was necessary, such as in emergency presentations or cases with irreducible hernias. Additionally, TAPP was performed in situations where external proctors provided guidance exclusively in that technique. While both techniques had distinct learning curves and complication profiles, this study focused on the impact of supervision on surgical outcomes rather than comparing TAPP vs. TEP. However, we acknowledged the potential influence of the chosen technique.

Hernia defect size was estimated intraoperatively by the operating surgeon. While measurements were recorded in centimetres for internal reference (e.g., ‘4 cm’ or ‘7 cm’), these values represented rounded visual estimates rather than precise measurements. All included cases were classified as European Hernia Society (EHS) Size 3 (>3 cm). The 7 cm cut-off was used as an institutional safety threshold for case selection during early-career training.

All meshes were 10 cm × 15 cm lightweight polypropylene, secured with absorbable tacks, and were not trimmed to maintain standardization during training. All surgeries were operated under general anesthesia. Any conversion from laparoscopic to open, intra-operation and immediate post-operation complications (i.e., adverse events occurring within the first 30 days following surgery) were recorded. Operation time was recorded for each surgery. All patients were followed up postoperatively at 1, 2, and 3 months to assess early complications, recurrence, and pain outcomes. Due to the study’s design and resource limitations, long-term follow-up beyond three months was not available. These findings represent short-term surgical outcomes rather than long-term efficacy. Pain was assessed by a Visual Analogue Scale (VAS) pain scoring system (i.e., from 0: no pain to 10: intolerable pain) and defined as VAS ≥3 at rest. Any recurrences and complications were assessed. Recurrence was defined as a clinically apparent bulge, confirmed with ultrasound when needed.

Statistical analysis

Data analysis was done by using IBM SPSS version 26 (IBM Corp., Armonk, N.Y., USA). Normality was assessed using histograms and the Shapiro-Wilk test. Continuous variables were described with mean and standard deviation (SD) while categorical variables were described with frequency and percentage (%). Fisher’s exact test was used for categorical variables where appropriate. The patient outcomes were reported by supervised and independently performed arms. T-test or Chi-squared test was performed accordingly.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Research & Ethics Committee (MREC) Malaysia, NMRR (ID-23-02241-K0U), and individual consent for this retrospective analysis was waived.

Training modules

This training module was organised by the General Surgery Department of HSAJB, in collaboration with Malaysia Hernia Society (MHS). The module comprised of two parts—seminar and workshop. The attendance and completion for both parts were compulsory for each participant.

Part 1: seminar and pre-workshop requirements

ECSs were also required to attend and assist in at least five cases of LIHR (a mix of TAPP and TEP approaches) performed by senior consultants. Their roles included port placement, dissection, mesh handling, and assisting in mesh fixation, with the objective of gaining proficiency in key procedural steps and anatomical recognition.

Prior to attending the workshop, ECSs were also required to attend and assist at least five cases of LIHR performed by the senior consultants.

Part 2: workshop

Two operation theatres were booked for a total of six practice cases of laparoscopic inguinal repair. The first case was demonstrated and performed by senior surgeons. Subsequent cases were operated by ECSs (1 operating, 1 assisting) under close supervision and guidance of the senior surgeons. The six workshop cases used for training and assessment were not included in the final cohort analysis. Each ECS performed at least one case as primary surgeon during this supervised workshop.

The training module was completed by five ECSs (1–3 years practicing as a general surgeon and had experiences assisting in inguinal hernia repair). The competency of each ECSs was assessed by proctors upon the completion of the module. Proctors assessed ECSs on dissection safety, sac reduction, mesh placement, and intraoperative judgment. Proctors were senior surgeons with >10 years’ experience. All were deemed competent, essentially based on each step of dissection and mesh placement which were adequately safe.

Following completion of the structured training module, all five ECSs commenced performing LIHRs. In accordance with institutional policy, their initial cases were conducted under direct supervision. Upon formal credentialing, based on demonstrated technical competency and intraoperative judgment, the surgeons transitioned to performing procedures independently. All cases included in this study were conducted after the completion of training. The supervised cases reflect the early post-training phase or were performed with oversight due to patient-specific or procedural complexity. This study compares short-term patient outcomes between supervised and independent cases as a measure of performance progression within the post-training period. It should be noted, however, that this comparison does not constitute a true pre- and post-training evaluation, as baseline performance data prior to training were not available.

Results

After completion of the training workshops, each ECS performed at least two inguinal hernia repairs under supervision and three independently as the main operating surgeon (Table 1).

There was a total of 42 patients (41 elective cases and 1 emergency case). One emergency case was included as the patient was stable, the hernia was reducible, and surgery proceeded electively after admission. The patients were predominantly males (41 males, 1 female) and their mean age was 54 years old (Table 2). There were 6 bilateral (14.3%), 14 unilateral left (33.3%) and 22 unilateral right (52.4%) inguinal hernias. Majority of the cases had empty sacs (n=39, 92.9%) while 3 were not empty (1 case with cord, 2 cases with omentum). Majority of them were indirect (n=39, 92.9%) and only 3 cases were direct (7.1%). The largest dimension of hernia size, based on the rounded intraoperative estimation, was 7 cm. Only 10 of the cases were recurrent hernias (23.8%) and all these cases were repaired via open surgery previously. All patients had no comorbidities at presentation.

Based on the EHS groin hernia classification (5), the descriptions of the cases were as below:

• P (primary hernia): 32 (76.2%);
• R (recurrent hernia): 10 (23.8%);
• Hernia size: size 3 for all 42 cases (i.e., >3 cm) (100%);
• L (lateral/indirect hernia): 39 (92.9%);
• M (medial/direct hernia): 3 (7.1%);
• F (femoral hernia): 0.

There were 14 cases of laparoscopic TAPP (33.3%) and 28 cases of laparoscopic TEP (66.7%).

One-third of cases were performed under supervision (n=14, 33.3%). Mesh was used in all cases (10 cm × 15 cm). All meshes were fixed with tacks. Only one case was converted from laparoscopic to open surgery (2.4%). The mean operating time for all included surgeries was 99 minutes, ranging from 36 to 164 minutes. Specifically, the mean operating time for supervised and independently performed procedures were 86 and 106 minutes respectively (P=0.052) (Table 2).

There was no major organ or vascular injury. Seven patients experienced pain at 1 month (16.7%) while only two patients experienced chronic pain at 3 months (4.8%). Only one patient had recurrence at 2 months (2.4%). There was no significant difference intraoperative and post-operative complications between both arms. Five cases required conversion from TEP to TAPP due to peritoneal breach, all in the independent group (Table 3).

Discussion

This study focused on the first 42 cases of LIHR performed by ECSs in a tertiary centre at Southern Malaysia, providing insight into the feasibility and safety of structured LIHR training for ECSs. The findings suggested that ECSs could achieve acceptable surgical outcomes following structured training. However, long-term follow-up and competency assessments were needed for continued evaluation.

Compared to prior studies on LIHR training, our results aligned with evidence suggesting that structured training programs enhance surgical competency and patient safety. Previous research showed that supervised surgical training reduced complication rates and improved operative efficiency, particularly during the early phase of skill acquisition (6,7). Although our study did not observe significant differences between supervised and independently performed procedures, this was consistent with a systematic review indicating that with appropriate training and sufficient experience, surgical trainees could operate at a level comparable to experts without compromising patient care (8).

One of the key challenges in early LIHR training was the learning curves associated with different techniques. TAPP and TEP had distinct technical requirements, learning curves and complication profiles (9). Our study included both techniques under the same training module, which might have introduced variability in outcomes. There were more TEP (n=28, 66.7%) performed than TAPP (n=14, 33.3%). The selection of TEP and TAPP depended on surgeon choice and the need of examination of intraabdominal organ. The senior local surgeon performed TEP as primary option of laparoscopic groin hernia repair due shorter operating hours and less dissection (no peritoneal flap creation) (9). TAPP was technically easier, having wider operative field and allowing inspection of intraabdominal organs for easier reduction of hernia contents. However, it had higher risks of intraabdominal organ injury and adhesive bowel obstruction (10). Future studies might consider stratifying training outcomes by technique to better assess whether a standardised approach to both methods was optimal.

The overall mean operating time for this series of LIHR was 99 minutes, which was longer than other reported studies (11,12). This could be explained by the learning curve and early experiences of the ECSs in this study. Existing literature suggested that skill acquisition in LIHR required 13 to 15 cases, with gradual improvements in operative efficiency and complication rates (4,13). Our study included ECSs performing LIHR independently after structured training, which might explain the longer durations observed. However, the slight increase in operating time for independently performed cases (106 vs. 86 minutes in supervised cases) supported the importance of ongoing mentorship during the learning phase. Previous studies showed significant improvement in operating time with increasing surgeon experiences, suggesting that the later cases in current series could buffered off the differences in operating time (14-16). Longer times in the independent group might reflect early learning curve, greater caution, and possibly more complex cases, whereas supervised procedures might have been expedited through real-time guidance.

The most common complication in this study was peritoneal breech. The majority of the cases occurred in laparoscopic TEP and this had caused two of the cases to be converted to laparoscopic TAPP. This was in alignment with a prospective study which reported peritoneal breech as one of the frequent complications and it might be due to the presence of a thin sac (17). The capability of ECSs to do both TEP and TAPP techniques following structured training, allowing the conversion to TAPP in the event of peritoneal breach in TEP causing intraperitoneal air leak. There was only one case converted to open. It was a case of elective TEP right recurrent inguinal hernia repair performed independently for a 64-year-old male, with history of open repair. The conversion was justified by the recurrent state of the hernia and adhesion from previous surgery. Although no formal simulation was used, the training module emphasized recognition of situations warranting conversion through seminars and consultant-supervised procedures. ECSs were taught practical intraoperative decision-making, which enabled safe conversion in a real-case scenario. The current series did not report any major organ or vascular injury, in contrary to a previous meta-analysis which reported high number of serious complications of visceral and vascular injuries (2).

Only a small number of patients experienced post-op pain at 1 month (n=7, 16.7%) and 3 months (n=2, 4.8%), which were all well-managed conservatively with oral analgesia. There was no surgical intervention and no pain specialist referrals. There was only one case of recurrence (2.4%) within the first two months, which, while lower than recurrence rates in long-term studies, emphasizes the need for extended follow-up (18). Notably, this recurrence was associated with small mesh size used in the previous open repair, factors known to influence recurrence risk (19). Prior studies have recommended a minimum mesh size of 10 cm × 15 cm for optimal outcomes, reinforcing the need for adherence to standardized guidelines in training programs (3). Although a standard 10 cm × 15 cm mesh was used in the current LIHR, the recurrence might have been influenced by tissue changes from a prior open repair with suboptimal mesh coverage. Surgical options were offered to the patient but no surgical intervention was performed as it was asymptomatic.

Strength and limitations

This study had limitations. The short follow-up period (three months) did not allow for a comprehensive assessment of long-term recurrence rates or chronic pain. Existing literature suggested that hernia recurrence can develop over months to years, necessitating prolonged surveillance (18). Future studies should include extended follow-up at six months, one year, and beyond.

This study was limited by its small sample size and single-centre design, which might affect the generalizability of the findings. Additionally, the heterogeneity of cases, including both primary and recurrent hernias as well as unilateral and bilateral presentations, introduced variability that complicated outcome comparisons. These limitations had been clearly acknowledged and should be considered when interpreting the findings.

Additionally, supervised cases reflected the early post-training phase or were conducted due to case complexity. While this comparison illustrated performance progression post-training, it did not represent a true pre- and post-training assessment. The lack of baseline data and a control group limited conclusions on skill acquisition. Future studies using objective tools like Objective Structured Assessment of Technical Skill (OSATS) or Direct Observation of Procedural Skills (DOPS) could better evaluate training effectiveness (20).

The inclusion of both TEP and TAPP approaches reflected the real-world training experience, where technique selection was influenced by surgeon preference, patient factors, and intraoperative findings. While this heterogeneity introduced variability in the operative outcomes and learning curve, it also mirrored typical clinical practice. We acknowledged that the lack of a strict decision algorithm might limit interpretability; however, the study aimed to capture outcomes within the pragmatic constraints of an evolving training program. Future studies with larger sample sizes might further analyse whether specific technique choice would affect the transition to independent practice.

Despite the limitations, the study had significant value to enhance regional development of laparoscopic hernia surgeries. Structured workshop and formal training must be encouraged before embarking upon the newer technique.

Conclusions

The findings of this study suggested that LIHR could be performed with acceptable early outcomes by ECSs who had completed a structured training module. No major complications or high recurrence rates were observed. However, due to the retrospective nature of the study and lack of a control group, these outcomes should be interpreted cautiously. Further prospective, controlled studies were recommended to more robustly evaluate the effectiveness of such training programs in improving surgical performance and patient outcomes.

Acknowledgments

None.

Footnote

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

Data Sharing Statement: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-35/dss

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

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Research & Ethics Committee (MREC) Malaysia, NMRR (ID-23-02241-K0U), and individual consent for this retrospective analysis was waived.

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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