Operative time and recurrence across five techniques of inguinal hernia repair: a Bayesian network meta-analysis of 29 randomized trials.

PURPOSE: To benchmark the clinical efficiency and safety of five inguinal hernia repair techniques-open surgery, conventional laparoscopy (TAPP and TEP), single-incision laparoscopic surgery (SILS), and robotic-assisted TAPP (r-TAPP)-to guide evidence-based surgical decision-making.

METHODS

Following PRISMA-NMA guidelines, we conducted a Bayesian network meta-analysis (NMA) of 29 randomized controlled trials (8,995 patients). Primary endpoints were operative time and recurrence; secondary outcomes included total complications and chronic pain. The certainty of evidence was systematically evaluated using the GRADE-NMA framework.

RESULTS

Open repair and conventional laparoscopy remained the most time-efficient approaches. Compared with open repair, r-TAPP was associated with longer operative time (MD 23.84 min; 95% CrI 2.74-44.29), and TAPP showed a moderate time penalty (MD 14.42 min; 95% CrI 1.02-28.04). For hernia recurrence, the current network remained statistically underpowered to detect clinically meaningful differences among the five modalities; all recurrence estimates were imprecise, particularly for the sparse r-TAPP (OR 1.44; 95% CrI 0.03-83.86) and SILS nodes. Minimally invasive approaches showed a numerically favorable trend toward less chronic pain relative to open repair, although certainty for this subjective outcome remained limited.

CONCLUSIONS

TEP provides the most favorable time-efficiency profile among minimally invasive options, while TAPP offers comparable safety with a moderate time penalty. However, we remain very uncertain about the effects of r-TAPP and SILS on recurrence and overall safety because of sparse-event data and very low-certainty evidence. The currently observed temporal penalty of r-TAPP in most general centers likely reflects early technology adoption and learning-curve effects rather than the ultimate ceiling of robotic efficiency.

TRIAL REGISTRATION: PROSPERO (CRD420261306112).