Learning curve in robotic inguinal hernia repair: a systematic review and meta-analysis

This study aims to perform a systematic review and meta-analysis to assess the learning curve in robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair in adult patients, emphasizing the number of procedures associated with improved operative efficiency and the evolution of operative performance over time.

A systematic review was conducted following PRISMA guidelines. A comprehensive search of PubMed/MEDLINE, Embase, Cochrane Library, Web of Science, Lilacs and SciELO was performed through March 2026, including cohort studies on adult patients undergoing elective robotic inguinal hernia repairs. Studies were eligible for quantitative synthesis if operative time was reported across distinct learning phases. Operative time between phases was pooled using a random-effects model, and mean differences (MD) with 95% confidence intervals (CI) were calculated. Heterogeneity was assessed using the I² statistic.

622 articles were screened, of which 13 met the inclusion criteria and were included in the systematic review. All studies evaluated learning curves in multiport rTAPP inguinal hernia repair. A total of 1,770 patients were included, of whom 1,465 were male (82.8%), with a mean BMI was 25.3 kg/m² (SD 3.3). Four studies defined two phases (learning and post-learning) and reported operative time per phase, allowing inclusion in the quantitative synthesis. A random-effects meta-analysis demonstrated a significant reduction in operative time between Phase 1 and Phase 2 (MD 17.02 min, 95% CI 5.91-28.14; I² = 86%). CUSUM-based studies for operative time in rTAPP reported a median proficiency threshold of 32 cases (IQR 18.5).

Among studies using operative-time-based CUSUM analyses, a median threshold of 32 cases was associated with improved operative efficiency in rTAPP, as reflected by reduced operative time. Progression beyond this initial learning phase is consistently associated with improved operative efficiency, including a pooled reduction of 17.02 min in operative time. Future studies should incorporate competency-based assessments and clinically meaningful outcomes to provide a more comprehensive evaluation of surgical proficiency.