Open and Laparoscopic Inguinal Hernia Surgery: A Cost Analysis

Costs of Robotic and Laparoscopic Bariatric Surgery: A Retrospective Propensity Score-matched Analysis

PURPOSE

Robotic bariatric surgery has not shown significant advantages compared to laparoscopy, yet costs remain a major concern. The aim of our study was to assess costs of robotic and laparoscopic bariatric surgery.

MATERIALS AND METHODS

We retrospectively collected data of all patients who underwent either robotic or laparoscopic bariatric surgery at our institution. We retrieved demographics, clinical characteristics, postoperative data, and costs using a bottom-up approach. The primary endpoint was hospital costs in the robotic and laparoscopic groups. Data was analyzed using a propensity score matching.

RESULTS

Out of the total 122 patients enrolled in the study, 42 were subsequently chosen based on propensity scores, with 21 patients allocated to each group. No difference in clinical characteristics and postoperative outcomes were noted. Length of hospital stay was 2.4 ± 0.7 days vs. 2.6 ± 1.1 days (p = 0.520). In the robotic and laparoscopic groups, total costs were USD 16,275 ± 4018 vs. 12,690 ± 2834 (absolute difference USD 3585, 95%CI 1416-5753, p = 0.002), direct costs were USD 5037 ± 1282 vs. 3720 ± 1308 (absolute difference USD 1316, 95% CI 509-2214, p = 0.002), and indirect costs were USD 11,238 ± 3234 vs. 8970 ± 3021 (absolute difference USD 2,268, 95% CI 317-4220, p = 0.024). Subgroup analyses revealed a decreasing trend in the cost difference in patients undergoing primary gastric bypass and revisional surgery.

CONCLUSIONS

Overall hospital costs were higher in patients operated on with the robotic system than with laparoscopy, yet a clinical advantage has not been demonstrated so far. Subgroup analyses showed lesser disparity in costs among patients undergoing revisional bariatric surgery, where robotics are likely to be more worthwhile.

Hospital costs of robotic-assisted and open treatment of large ventral hernias

Robotic-assisted treatment of ventral hernia offers many advantages, however, studies reported higher costs for robotic surgery compared to other surgical techniques. We aimed at comparing hospital costs in patients undergoing large ventral hernia repair with either robotic or open surgery. We searched from a prospectively maintained database patients who underwent robotic or open surgery for the treatment of the large ventral hernias from January 2016 to December 2022. The primary endpoint was to assess costs in both groups. For eligible patients, data was extracted and analyzed using a propensity score-matching. Sixty-seven patients were retrieved from our database. Thirty-four underwent robotic-assisted surgery and 33 open surgery. Mean age was 66.4 ± 4.1 years, 50% of patients were male. After a propensity score-matching, a similar total cost of EUR 18,297 ± 8,435 vs. 18,024 ± 7514 (p = 0.913) in robotic-assisted and open surgery groups was noted. Direct and indirect costs were similar in both groups. Robotic surgery showed higher operatory theatre-related costs (EUR 7532 ± 2,091 vs. 3351 ± 1872, p < 0.001), which were compensated by shorter hospital stay-related costs (EUR 4265 ± 4366 vs. 7373 ± 4698, p = 0.032). In the treatment of large ventral hernia, robotic surgery had higher operatory theatre-related costs, however, they were fully compensated by shorter hospital stays and resulting in similar total costs.

Safety and feasibility of emergency robot-assisted transabdominal preperitoneal repair for the treatment of incarcerated inguinal hernia: A retrospective study

BACKGROUND

Few studies assessed robotic in emergency setting and no solid evidence was demonstrated. The aim of this study was to evaluate the feasibility and safety of robot-assisted transabdominal preperitoneal (R-TAPP) repair for the treatment of incarcerated inguinal hernia.

METHODS

We retrospectively searched from a prospectively maintained database patients who underwent R-TAPP or open surgery for incarcerated inguinal hernias from January 2018 to March 2023. The primary endpoint was to assess safety and feasibility of the R-TAPP compared to the standard approach. For eligible patients, data was extracted and analyzed using a propensity score-matching (PSM).

RESULTS

Thirty-four patients were retrieved from our database, 15 underwent R-TAPP, while 19 underwent open surgery. Mean age was 73.1 ± 14.6 years, 30 patients (88.2%) were male and mean BMI was 23.5 ± 3.2 kg/m2. No intraoperative complication occurred. Three cases requiring small bowel resection were all in the open surgery group (p = 0.112). The operative time was 108 ± 31 min versus 112 ± 31 min in the R-TAPP and open surgery groups (p = 0.716). Seven postoperative complications occurred, only one classified as severe was in the open surgery group. The length of hospital stay was 2.9 ± 1.8 in the R-TAPP versus 4.2 ± 2.3 min in the open surgery group (p = 0.077). PSM analysis showed similar postoperative outcomes and costs in both groups.

CONCLUSIONS

Despite its limitations, our study appears to endorse the safety and feasibility of the robotic-assisted treatment for incarcerated inguinal hernia. This approach yielded comparable results to open surgery, albeit in a limited number of patients, suggesting it might be a viable alternative.

Cytomorphological Effects of Lightweight and Heavyweight Polypropylene Mesh on the Ilioinguinal Nerve: An Experimental Study

Objective This study aimed to investigate the cytomorphological effects of heavyweight and lightweight mesh on the ilioinguinal nerve in an experimental animal model. Methods Sixteen New Zealand male rabbits were included in the study. The left inguinal regions of the first six animals were assigned as controls and the right inguinal regions were assigned as the sham group. The left inguinal regions of the remaining 10 animals were assigned as the lightweight mesh group and the right inguinal regions were assigned as the heavyweight mesh group. No intervention was performed in the control group. In the sham group, only ilioinguinal nerve exploration was performed. In mesh groups, ilioinguinal nerve exploration was performed and the mesh was implanted on the ilioinguinal nerve. After three months, ilioinguinal nerve specimens were excised from both sides for cytomorphological examination. Results Myelin sheath thickening, separation of the myelin layers, and myelin vacuolization were more pronounced in the heavyweight mesh group compared to the lightweight mesh group. The G-ratio was moderately increased in the heavyweight mesh group when compared to other groups. The ratio of fibers with ≤4 µm diameter was higher in the lightweight mesh group compared to other groups, and the ratio of fibers with ≥9 µm diameter was higher in the heavyweight mesh group than in the other groups (p<0.05). Conclusion Both of the meshes induce cytomorphological alterations on the adjacent nerve tissues caused by foreign body reaction and compression. Ilioinguinal nerve degeneration was more pronounced in the heavyweight mesh than in the lightweight mesh. Histological alterations on the ilioinguinal nerves caused by different meshes may be related to chronic pain after hernia surgery. We believe our study will serve as a guide for future studies on the topic.

Costs and recurrence of inguinal hernia repair in premature infants during neonatal admission

BACKGROUND

Timing of inguinal hernia repair (IHR) in premature infants remains variable, yet the impact of IHR timing on procedure costs and recurrence is unclear. We sought to compare cost and recurrence rates of IHR in premature infants based on timing of repair.

METHODS

We performed a retrospective cohort study using MarketScan insurance claims data from 2007 to 2018 to evaluate IHR occurring within 365 days of birth in preterm infants (gestational age [GA]<37 weeks at birth). Patients were stratified based on timing of IHR: those occurring during and after neonatal discharge. Hernia recurrences within one year following IHR were identified. Patient demographic characteristics and costs were compared between groups. Time to recurrence and cumulative recurrence hazards were estimated using Kaplan Meier analysis and Cox proportional hazards regression.

RESULTS

We identified 3,662 preterm infants with IHR within 365 days of birth; 1,054(28.8%) occurred early. Infants with IHR during NICU stay were more likely to have GA at birth≤32 weeks (74.7% vs. 37.2%; p<0.01) and birthweight<1500 g (83.0% vs. 40.3%; p<0.01) compared to post-NICU IHR. The hernia recurrence rate was higher and total procedure costs lower in early IHR. Early IHR (HR:1.86, 95% CI: 1.56-2.22), incarcerated/strangulated hernia (HR:1.86, 95% CI:1.49-2.32), GA≤32 weeks (HR: 1.40, 95% CI: 1.19-1.65), and congenital anomalies (HR: 1.32, 95% CI: 1.12-1.57) were predictors of hernia recurrence.

CONCLUSION

Using insurance claims data, IHR performed during initial neonatal admission was associated with lower cost, but higher recurrence rate, when compared to delayed repairs in preterm infants.

TYPE OF STUDY

Retrospective study LEVEL OF EVIDENCE: Level III.

Comparison of Postoperative Outcomes of Laparoscopic vs Open Inguinal Hernia Repair

Importance

Advocates of laparoscopic surgery argue that all inguinal hernias, including initial and unilateral ones, should be repaired laparoscopically. Prior work suggests outcomes of open repair are improved by using local rather than general anesthesia, but no prior studies have compared laparoscopic surgery with open repair under local anesthesia.

Objective

To evaluate postoperative outcomes of open inguinal hernia repair under general or local anesthesia compared with laparoscopic repair.

Design, Setting, and Participants

This retrospective cohort study identified 107 073 patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent unilateral initial inguinal hernia repair from 1998 to 2019. Data were analyzed from October 2021 to March 2022.

Exposures

Patients were divided into 3 groups for comparison: (1) open repair with local anesthesia (n = 22 333), (2) open repair with general anesthesia (n = 75 104), and (3) laparoscopic repair with general anesthesia (n = 9636).

Main Outcomes and Measures

Operative time and postoperative morbidity were compared using quantile regression and inverse probability propensity weighting. A 2-stage least-squares regression and probabilistic sensitivity analysis was used to quantify and address bias from unmeasured confounding in this observational study.

Results

Of 107 073 included patients, 106 529 (99.5%) were men, and the median (IQR) age was 63 (55-71) years. Compared with open repair with general anesthesia, laparoscopic repair was associated with a nonsignificant 0.15% (95% CI, -0.39 to 0.09; P = .22) reduction in postoperative complications. There was no significant difference in complications between laparoscopic surgery and open repair with local anesthesia (-0.05%; 95% CI, -0.34 to 0.28; P = .70). Operative time was similar for the laparoscopic and open general anesthesia groups (4.31 minutes; 95% CI, 0.45-8.57; P = .048), but operative times were significantly longer for laparoscopic compared with open repair under local anesthesia (10.42 minutes; 95% CI, 5.80-15.05; P < .001). Sensitivity analysis and 2-stage least-squares regression demonstrated that these findings were robust to bias from unmeasured confounding.

Conclusions and Relevance

In this study, laparoscopic and open repair with local anesthesia were reasonable options for patients with initial unilateral inguinal hernias, and the decision should be made considering both patient and surgeon factors.

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward.

Routine histopathologic examination of the resected specimen after laparoscopic sleeve gastrectomy - what can be expected?

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is nowadays an established bariatric procedure. Although preoperative gastroscopy is recommended to rule out severe pathologies, there is little evidence about the role of routine histopathologic examination of resected specimens. We sought to identify the prevalence of histopathological relevant findings in patients undergoing LSG and to evaluate their impact in clinical practice.

METHODS

A retrospective analysis on a prospectively collected dataset on patients undergoing LSG between August 2009 and May 2018 in two bariatric centers was performed. Demographic and clinical data and histopathological results were analyzed.

RESULTS

Sixhundred-thrirteen patients were identified, mean age was 43.1 years (14-75), average body mass index was 44.8 kg/m² (34.4-73.9). Histopathology revealed abnormal findings in 47.97% of the patients, most common pathology was chronic non-active or minimally to moderate active gastritis (n = 202;32.95%). Among others, Helicobacter-associated gastritis (n = 33;5.38%), intestinal metaplasia (n = 13;2.12%), micronodular enterochromaffine-like cell hyperplasia (n = 2; 0.33%) and gastrointestinal stromal tumors (n = 6; 0.98%) were present. No malignancies were found. Histopathological results required a change in the postoperative management in 48 patients (7.83%). The costs of histopathological assessment ranged between 0.77% and 2.55% of per-case payment.

CONCLUSION

A wide range of histopathological findings occur in specimens after LSG, requiring a relevant number of patients additional therapies or surveillance. Therefore, routine histopathological examination after LSG is recommendable.

Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

Ultrasound-Guided Pudendal Nerve Block in Patients Undergoing Open Hemorrhoidectomy: A Post-Hoc Cost-Effectiveness Analysis from a Double-Blind Randomized Controlled Trial

Background

Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy.

Methods

From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed.

Results

Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482±386 vs 613±543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606±816 vs 2769±1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of −243 ± 881 EUR/pain unit on the VAS.

Conclusion

Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.

Contribution margin per hour of operating room to reallocate unutilized operating room time: a cost-effectiveness analysis

BACKGROUND AND OBJECTIVES

Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to calculate CMH and to increase cost-effectiveness.

METHODS

For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH.

RESULTS

Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random "first come-first serve" basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001).

CONCLUSION

Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.

Robot-assisted Treatment of Epigastric Hernias With a Suprapubic Approach

BACKGROUND

Robot-assisted ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are placed laterally to meet the distance from the fascial defect. The aim of our study is to report our experience of epigastric hernia treatment with trocar insertion in the suprapubic region.

MATERIALS AND METHODS

On a prospectively collected dataset on robot-assisted surgery, patients treated for epigastric hernias with suprapubic approach were identified. Demographic and clinical data were collected and analyzed.

RESULTS

Twelve patients were selected. Median age was 58.5 years [interquartile range (IQR): 47.8 to 67.3 y]; 4 patients were male (33.3%) and the median body mass index was 23.9 kg/m2 (IQR: 22.3 to 26.2 kg/m2). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR: 13.75 to 31.0 mm); median larger mesh diameter was 13.5 cm (IQR: 9.5 to 15.0 cm); and median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication or conversion to open surgery occurred. Postoperatively, 2 patients presented a seroma and median length of hospital stay was 2.0 days (IQR: 1.75 to 3 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 4 to 29 mo).

CONCLUSIONS

In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.

Identification and economic burden of main adverse events of nerve injuries caused by regional anesthesia: a systematic review

BACKGROUND AND OBJECTIVES

Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: ("regional anesthesia" OR "nerve block") AND ("complications" OR "nerve lesion" OR "nerve damage" OR "nerve injury"). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed.

RESULTS

Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000.

CONCLUSIONS

Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

Learning curve of robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias

BACKGROUND

Learning curves describe the rate of performance improvements according to the surgeon's caseload, followed by a plateau where limited additional improvements are observed. The aim of this study was to evaluate the learning curve for robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias in surgeons already experienced in laparoscopic TAPP.

METHODS

The study was approved by local ethic committee. Male patients undergoing rTAPP for inguinal hernia from October 2017 to December 2019 at the Bellinzona Regional Hospital were selected from a prospective database. Demographic and clinical data, including operative time, conversion to laparoscopic or open surgery, intra- and postoperative complications were collected and analyzed.

RESULTS

Over the study period, 170 rTAPP were performed by three surgeons in 132 patients, and mean age was 60.1 ± 13.7 years. The cumulative summation (CUSUM) test showed a significant operative time reduction after the 43^rd operation, once the 90% proficiency on the logarithmic tendency line was achieved. The corrected operative time resulted 71.1 ± 22.0 vs. 60.8 ± 13.5 min during and after the learning curve (p = 0.011). Only one intraoperative complication occurred during the learning curve and required an orchiectomy. Postoperatively, three complications (one seroma, one hematoma, and one mesh infection) required invasive interventions during the learning curve, while no cases were recorded after it (p = 0.312).

CONCLUSION

Our study shows that the rTAPP, performed by experienced laparoscopists, has a learning curve which requires 43 inguinal hernia repairs to achieve 90% proficiency and to significantly reduce the operative time.

Suture and Fixation of the Transversalis Fascia during Robotic-Assisted Transabdominal Preperitoneal Hernia Repair to Prevent Seroma Formation after Direct Inguinal Hernia Repair

Background. Seroma formation after videoendoscopic repair of inguinal hernias, known as "pseudorecurrence", may vary from an asymptomatic, self-limiting occurrence to a painful, chronic problem. The aim of this study was to investigate the incidence of postoperative seroma in robotic-assisted transabdominal preperitoneal hernia repair (R-TAPP), modified by suturing and fixating the transversalis fascia to the Cooper ligament. Methods. The study was approved by the local ethics committee (2019-01132 CE-3495). Patients undergoing R-TAPP for direct inguinal hernia from October 2017 to December 2019 were included. In all patients, a barbed running suture of the transversalis fascia was performed to close the cavity resulting from the direct hernia reduction and to fix it to the Cooper ligament, then a lightweight mesh was placed. Demographic and clinical data were collected and analysed. Results. Over the study period, 67 R-TAPP in 51 patients were identified. All patients were male, with a mean age of 63.1 ± 12.7 years. There was 1 case of conversion to open surgery due to adhesions of the caecum to the groin as a result of perforated appendicitis. The mean length of the hospital stay was 1.8 ± .6 days. After discharge, no cases of seroma or recurrence at 30 days nor chronic pain at a mean follow-up of 10.3 ± 6.8 months was detected. Conclusions. In the treatment of direct inguinal hernia with R-TAPP, suturing and anchoring the transversalis fascia to the Cooper ligament are safe, feasible and recommendable in order to prevent postoperative seromas.

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.