Developing a Scoring System for the Objective Assessment of Totally Extraperitoneal Minimally Invasive Inguinal Hernia Repair Surgery

Background While existing checklists and scoring systems assess open surgery and TAPP (transabdominal preperitoneal procedure) surgeries, there is currently a lack of evaluation criteria and a dedicated checklist for TEP (totally extraperitoneal procedure) surgery. This study aims to develop a comprehensive checklist for guiding the procedural steps of minimally invasive TEP surgery and to establish a scoring system applicable to resident training. Methods This observational study, conducted at a single center, involved the evaluation of 60 unedited surgery videos performed by expert surgeons and 34 videos of residents by two independent experts. İnter-rater reliability between the two evaluators and construct validity of the scoring system assessed. Results The study demonstrated a robust level of inter-rater reliability, with a Cronbach's Alpha coefficient of 0.94. The median score (Interquartile Range, IQR) of resident surgeons was significantly lower than that of expert surgeons (17 [14-19] vs. 18.5 [17–19.375], p <0.01). However, the median score of senior resident surgeons did not exhibit a statistically significant difference compared to expert surgeons (17 [16–20] vs. 18.5 [17–19.375], p = 0.192). Conclusion The developed scoring system demonstrates efficacy in evaluating TEP surgery and indicates a correlation with experience. Further investigations are needed to assess its applicability in diverse settings. TEP Checklist Trocar insertion - 4 points Entering the preperitoneal space by taking the rectus muscle laterally 0 1 2 Entering adequately two trocars of 5 mm in the pre-peritoneal space 0 1 2 Creation of the preperitoneal space- 6 points Identifying the pubic symphysis in medially 0 1 2 Developing space laterally to the level of SIAS 0 1 2 Identifying the epigastric vessels and staying below it ventrally 0 1 2 Reduction of hernia sac - 4 points Reduction of hernia sac and cord lipomas 0 1 2 Peeling away the peritoneum down to the Cooper's ligament 0 1 2 Description of anatomy - 4 points Identification of ductus deferens and spermatic vessels 0 1 2 Determining the location of the iliac artery and vein 0 1 2 Mesh deployment - 2 points Closing all the potential hernia defects with an excellent appearance 0 1 2 TOTAL 20