Trans-arcuate line vs. transumbilical access in single-port TEP groin hernia repair: a propensity score-matched retrospective cohort study

Background/objective Groin hernia is a common surgical condition requiring improved techniques. This study compares perioperative and postoperative outcomes of trans-arcuate line vs. pre-posterior sheath transumbilical approaches in single-port totally extraperitoneal (TEP)hernia repair. Method A retrospective cohort study included 297 patients with groin hernia who underwent single-port TEP hernia repair. After excluding 5 cases and applying propensity score matching (PSM), patients were divided into the transumbilical group ( n = 83) and the trans-arcuate line group ( n = 83) according to the surgical approach. Outcomes included operative time, peritoneal injury rate, postoperative pain score measured by the Visual Analogue Scale (VAS), haematoma, and intraoperative blood loss. CUSUM analysis was performed to assess operative-time learning curves in both groups, followed by subgroup analyses stratified into the learning and post-transition phases. Baseline characteristics were generally comparable between groups in the learning phase, although some imbalances were observed given the small sample size. For post-transition cases, propensity score re-matching was performed before comparison. Results After PSM, the trans-arcuate line group had significantly shorter operative time and a markedly lower incidence of intraoperative peritoneal injury than the transumbilical group. Early postoperative VAS pain scores were also significantly lower in the trans-arcuate line group ( P < 0.001). However, no statistically significant differences were observed in intraoperative blood loss or haematoma between the two groups. CUSUM analysis further revealed a longer learning phase in the trans-arcuate line group. Within the learning phase, this group had a lower peritoneum or hernia sac tearing rate, whereas in the post-transition phase, it had shorter operative time. Notably, when the comparison was restricted to post-transition cases after re-matching, peritoneum or hernia sac tearing rate and VAS scores no longer differed between groups. Conclusion After PSM and phase-stratified analysis, the trans-arcuate line approach was associated with a lower peritoneum or hernia sac tearing rate during the learning phase, and with shorter operative time after proficiency was reached. These findings suggest that the trans-arcuate line approach may offer distinct advantages at different stages of the learning curve, and the trans-arcuate line approach may be considered a favorable alternative after sufficient surgical experience has been acquired.