Assessing surgical residents' knowledge of totally extraperitoneal hernia repair: Anatomical landmarks and technical...

Totally extraperitoneal (TEP) inguinal hernia repair is widely favoured for its minimally invasive nature and favourable clinical outcomes. However, it presents a steep learning curve due to its reliance on in-depth knowledge of complex posterior inguinal anatomy and advanced laparoscopic skills. This study aimed to assess surgical residents' understanding of the anatomical and technical components essential for safe and effective TEP repair.

A cross-sectional study was conducted at the Etlik City Hospital, Ankara, in June-July 2025, involving 73 general surgery residents. Participants completed a 25-item multiple-choice questionnaire assessing the knowledge of TEP-specific anatomical landmarks (17 questions) and operative technique (8 questions). Demographic data, surgical experience (TEP cases performed and assisted) and post-graduate year were recorded. Each correct answer was awarded four points (total: 100). Receiver operating characteristic curve analysis identified 29 performed cases as the threshold for satisfactory performance (area under the curve = 0.82, 95% confidence interval [CI] 0.71-0.91). Residents were grouped into novice (≤29 cases) and experienced (>29 cases) cohorts. Statistical comparisons were performed using t-tests, ANOVA and Spearman correlation.

The mean age of the participants was 28.8 ± 2.2 years; 76.7% were male. The mean number of TEP procedures performed was 17.2 ± 34.2 and assisted was 30.8 ± 40.4. Experienced residents scored significantly higher than novices in anatomy (61.3 vs. 40.1, P < 0.001), technique (29.5 vs. 19.7, P < 0.001) and total score (90.8 vs. 59.8, P < 0.001, Cohen's d = 1.96, 95% CI 1.3-2.6). Anatomy question performance differed significantly on 13 of 17 items, particularly in identifying the triangle of doom and inferior epigastric vessels. Technical performance differed significantly on 6 of 8 items. A positive correlation was found between the number of assisted cases and total score (R² =0.386), with each three assisted cases associated with a 1-point increase.

Significant knowledge differences in TEP hernia repair exist between novice and experienced residents, strongly associated with procedural volume. TEP represents a valuable educational opportunity for posterior groin anatomy and technical skill development. Structured training programmes emphasising real-time exposure, simulation and anatomy-based feedback may accelerate the learning curve.