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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 63-69

Teaching and learning of laparoendoscopic hernia surgery in India: A challenge – problems and solutions

1 Department of General and Minimally Invasive Surgery, Mahatma Gandhi Hospital; Department of General and Minimally Invasive Surgery, Mahatma Gandhi University of Medical Sciences, Jaipur, Rajasthan, India
2 Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Date of Submission24-Mar-2019
Date of Acceptance14-Apr-2019
Date of Web Publication10-May-2019

Correspondence Address:
Dr. Mahesh C Misra
Mahatma Gandhi University of Medical Sciences, Sitapura, Jaipur - 302 024, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_10_19

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INTRODUCTION: One German surgeon (Eric Mühe in 1985)* and three French surgeons** (Philippe Mouret in 1987, Jacque Perissat in 1989, and Dubois F in 1990) are credited with having performed first* laparoscopic cholecystectomy and first** video-assisted laparoscopic cholecystectomy, respectively. Laparoscopic cholecystectomy became the procedure of choice (gold standard) for benign symptomatic gallbladder disease as well as asymptomatic gallbladder stones in India. There have been adoption and acceptance for laparoendoscopic incisional/ventral hernia repair. Actually, laparoendoscopic repair of incisional/ventral hernia, laparoscopic solid organ removal (spleen and adrenal), and laparoscopic fundoplication (gold standard) have been standard of care even in the absence of Level 1 evidence over the past three decades.
AIM: However, acceptance, adoption, adaptation, and performance of laparoendoscopic groin hernia surgery have been slow over the past three decades among practicing surgeons and surgical trainees.
RESULTS: The laparoendoscopic groin hernia repair has yet not gained the same status as for the procedures mentioned above (VS). The reasons are multifactorial and relate to obtaining adequate and proper training covering laparoendoscopic groin hernia repair. The first and foremost reason is that endoscopic repair of groin hernia is considered an advanced laparoscopic procedure as opposed to open hernia repair. Preceptorship–proctorship (PP) model, which worked extremely effectively for teaching and learning of laparoscopic cholecystectomy, could not be established for groin hernia yet. There is no effective simulator developed for any of the standardized techniques, i.e., totally extraperitoneal (TEP) and/or transabdominal preperitoneal repair (TAPP). The complications, for example, intestinal obstruction and major vascular injury, which were never seen during open era, also brought about criticism as well hampered the growth of laparoendoscopic groin hernia repair. In emerging economies such as India and other Asian countries, high cost of laparoendoscopic repair (tacker and specialized meshes) has been responsible for reduced penetration among practicing surgeons and patients. Therefore, the laparoendoscopic repair of groin hernia has been limited to major metropolitan corporate hospitals and small number of tertiary care public hospitals in metropolitan cities. The advantages of minimally invasive approaches for the repair of groin hernias have not benefited the masses in rural and semi-urban geographic areas of India.
CONCLUSION: Training opportunities for the teaching and learning laparoendoscopic repair of groin hernia have remained limited for vast majority of practicing surgeons and surgical trainees in India. With development of cadaveric (TEP and TAPP) and live anesthetized animal model (TAPP), it has been possible to establish training opportunities for practicing surgeons at few institutions. We also recommend and encourage expert surgeons to provide training opportunities for those who wish to learn the surgical skills of laparoendoscopic repair of groin hernia by giving their time for PP model. Furthermore, establishment of specialized hernia centers will go a long way to fill this void.

Keywords: Cadaveric model of hernia training, endoscopic hernia repair, laparoscopic cholecystectomy, IPOM, laparoscopic hernia repair, TAPP, TEP

How to cite this article:
Misra MC, Krishna A, Baksi A, Bansal VK. Teaching and learning of laparoendoscopic hernia surgery in India: A challenge – problems and solutions. Int J Abdom Wall Hernia Surg 2019;2:63-9

How to cite this URL:
Misra MC, Krishna A, Baksi A, Bansal VK. Teaching and learning of laparoendoscopic hernia surgery in India: A challenge – problems and solutions. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2022 Oct 7];2:63-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/2/63/257975

  Introduction Top

Brief history of modern operative laparoscopy.

  Evolution of Operative Laparoscopy in India Top

Erich Mühe from Germany is credited with performing the first celioscopic (laparoscopic) removal of the gallbladder in 1985–1986.[1] On March 17, 1987, Philippe Mouret performed the first laparoscopic cholecystectomy using pneumoperitoneum, in Lyon, France. This date represents a profound epistemological leap: “before that, there was nothing, after that there was laparoscopic surgery.”[2] In our considered opinion, these surgeons should be nominated jointly for the Nobel Prize in Medicine for changing lives of millions of patients worldwide over three decades. It also brought about revolution in the techniques of minimally invasive surgery across different surgical subspecialties benefitting millions of patients globally.

Laparoscopic cholecystectomy gained ground soon after the video demonstration of the procedure by the French surgeon Perissat in 1989 at SAGES meeting.[3] Dubois et al.[4] (1990) published an initial experience of 36 laparoscopic cholecystectomies as the first publication.

It did not take long before laparoscopic cholecystectomy was adopted and adapted by both surgeons and patients and spread like a wildfire. In the early nineties, we thought that laparoscopic cholecystectomy would replace the open procedure by the turn of the century; however, it happened much earlier. In fact, laparoscopic cholecystectomy became the procedure of choice much sooner than expected and became the “gold standard” even in the absence of Level 1 evidence.

Dr. Tehemton Udwadia, from Mumbai, is credited with performing the first laparoscopic cholecystectomy in India in the year 1990.[5] We, at the All India Institute of Medical Sciences (AIIMS), New Delhi, performed our first laparoscopic cholecystectomy in November 1991. Actually, our introduction to operative laparoscopy began with a 15-min video home system (VHS) of laparoscopic cholecystectomy by Dr. Mohan Chellappa from Singapore.[6] I remember watching that video minutely ten times before performing my first laparoscopic cholecystectomy. Actually, my first laparoscopic removal of the gallbladder was performed looking directly through the telescope like trans-urethral resection of prostate (TURP) in those days because our first endocamera was not delivered that affirmed the passion for entering into a new era of “operative laparoscopy” in India. India is a vast country and several surgeons took the lead all across India (Pradeep Chowbey in North India, K Ravindranath and Surendra Ugale in South India, and many others) to have begun operative laparoscopy by taking up the challenge of laparoscopic cholecystectomy. The gallbladder in human body is credited with teaching and learning laparoscopic skills, i.e., orientation to magnified anatomy, working with both hands, hand–eye coordination, depth perception, and handling laparoscopic instruments with 6° (up and down, right and left, and in and out) of movements with limited ergonomics in the beginning.

It led to worldwide acceptance by surgeons and patients because of the obvious advantages of minimally invasive surgery or less invasive operation avoiding a large incision and its morbidity. However, there were sceptics among the very many senior surgeons, and they had their reasons due to increased incidence of common bile duct injuries and mishaps (including deaths) being reported sporadically during the performance of laparoscopic cholecystectomy that did not dampen the interest among younger surgeons to learn the laparoscopic technique with the help of those who took the lead. Many of the surgeons (VS) were traveling all across the country to teach the technique. A local surgeon/hospital would invite an “expert surgeon” and enroll patients willing for laparoscopic removal. I (MCM) still remember having performed 40 laparoscopic cholecystectomies over 3 days in Guwahati, Northeast India, in 1994. On day 1, I (MCM) performed all the procedures and a local surgeon assisted me holding the camera. On day 2, the local surgeon performed the procedure and I held the camera and took over if the procedure was difficult. On day 3, the local surgeon performed with his team and I supervised and scrubbed if there was any problem. This is commonly known as the “preceptorship–proctorship model.” Preceptorship is the situation where a trainee surgeon goes to the trainer surgeon's hospital to observe and be taught. Thus, in preceptorship–proctorship (PP) model, the preceptor (trainee) is responsible for both patient cares during training by the visiting surgeon (proctor). Proctorship is defined as the situation where an experienced surgeon (proctor) spends some time at a trainee's (preceptor) hospital helping with the first few cases. The proctor is responsible only for teaching, while patient care is the responsibility of the trainee surgeon (preceptor). The “preceptorship–proctorship model” has proved to be a safe and effective way to teach and learn newer surgical skills in operative laparoscopy. Although simulator-based training has been proved to be effective, there is no doubt that the only way to learn laparoscopic procedures satisfactorily is to perform the procedure in question under guidance on a live case (patient) with keeping patient safety uppermost. The PP model can prove to be very effective in bridging the gap between training on simulators and performing actual laparoscopic operations independently.

Minimally invasive surgery was rapidly gaining momentum and was being applied to newer surgical procedures. Two procedures were considered “gold standard” even in the absence of any Level 1 evidence, i.e., laparoscopic cholecystectomy[7] and laparoscopic Nissen fundoplication.[8] Laparoscopic removal of solid organs such as spleen and adrenal was next to become standard of care without Level 1 evidence.[9],[10] Laparoscopic cholecystectomy paved the way for the use of minimal access today across all surgical specialties. Millions of patients across the world have benefited, but newer complications have also been reported following laparoscopic procedures. There was a comparison between complications following open (30 complications) versus laparoscopic cholecystectomy (130 complications).

  Laparoendoscopic Hernia Surgery Top

There are two common elective surgical procedures a trainee general surgeon is taught and learns, namely cholecystectomy and repair of groin hernia. With the advent and success of laparoscopic cholecystectomy, minimal access has been applied to both groin and ventral/incisional hernia. Intra-peritoneal onlay mesh (IPOM) for small- and moderate-sized incisional and primary ventral hernias became the standard of care even in the absence of Level 1 evidence due to overwhelming advantages of minimal access.

Unlike cholecystectomy, adaptation and adoption of laparoendoscopic repair of hernia particularly groin hernia have been slow both among surgeons and patients. This is largely due to the fact that open operation for groin hernia is simple to teach and can be performed under local anesthesia. It was also because laparoendoscopic techniques were not standardized in early years. Prior to the development of standardized techniques of totally extraperitoneal/transabdominal preperitoneal repair (TEP/TAPP), various other techniques were undertaken for laparoendoscopic repair of groin hernia, and these included IPOM, plug and patch, and simple ring closure. Low recurrence rates were reported in a large multicentric study by Tetik et al.[11] for TEP (0.42%), TAPP (0.7%), IPOM (2.2%), and simple ring closure (3%). However, plug and patch technique was associated with 22% recurrences. Surgeons started performing IPOM for groin hernia and the technique led to high recurrence rates and other complications (e.g., intestinal obstruction). Neumayer et al.[12] published higher recurrence rates following laparoendoscopic repair of groin hernia (10.1%) as compared to open repair (4%). In their conclusion, they said that open technique is superior to the laparoscopic technique for mesh repair of primary hernias. However debited afterward, as a possible reason for the high recurrence rate, it was recognized that some of the involved surgeons used a too small mesh.[13]

My introduction to laparoscopic groin repair was in January 2003. We invited Prof. T Yamakawa from Japan, who performed live demonstration of laparoscopic cholecystectomy, laparoscopic bile duct exploration, and also TAPP repair of groin hernia. Tacks were used for fixing the peritoneal flap covering mesh. Laparoscopic suturing was yet a distant dream for most surgeons performing laparoscopic cholecystectomy. It was used to take considerable time for taking sutures intraperitoneally. We started performing TAPP in small numbers. An Australian surgeon Eric Tan visited India and held live operative workshop at Sir Ganga Ram Hospital, New Delhi. In 1994, Eric Tan demonstrated the technique of TEP repair of groin hernia. We invited him to visit the Department of Surgical Disciplines, AIIMS, New Delhi, and go onward rounds with us. He invited us to participate in the meeting of Endoscopic and Laparoscopic Surgeons of Asia in October 1994 at Perth, Australia. During this conference, Michelle Gagner presented his experience with the first laparoscopic Whipple's operation. Laparoendoscopic hernia surgery was still not discussed in a significant proportion. The problems in the acquisition of laparoendoscopic groin hernia surgery have been largely two-fold:

  1. Lack of standardization of laparoendoscopic techniques
  2. Lack of training opportunities for teaching and learning both TAPP/TEP.

Development of two standardized techniques of laparoendoscopic surgery of groin hernia has been slow because of the obvious advantages of open approaches and cost-effectiveness. However, progress continued, and some individuals are always ahead of others. The same has been true for development of laparoendoscopic surgery of groin hernia worldwide and in India, too. The standardization of TEP technique has been credited to George Ferzli (USA)[14] and Dulucq (France)[15] and TAPP to Prof. Reinhard Bittner (Germany).[16]

I must say that I learned the standardized technique of TAPP when I visited Prof. Reinhard Bittner's Centre in Stuttgart, Germany, in 2006. We were performing TAPP prior to that but Prof. Bittner's technique has been the best I would say. I have not seen many surgeons closing the peritoneal flap as meticulously as Prof. Bittner does even today.

When we look at the adaptation and adoption of laparoendoscopic groin hernia surgery, it is still slow despite standardization of techniques of both TEP and TAPP. A major issue with laparoendoscopic groin hernia surgery is that it is considered an “advanced laparoscopic procedure,” while open groin hernia repair is a basic surgical procedure, which is taught and learned by every general surgical trainee. The principal reasons for slow penetration of TEP/TAPP have been due to limited training opportunities. PP model, which worked for laparoscopic cholecystectomy so well, has not become popular for laparoendoscopic surgery of groin hernia. Somehow, surgeons are not able to collect as many hernia patients as with gallstone disease for live operative workshops. Although the high prevalence of groin hernias in males makes it the most common general surgical procedure performed in the USA and in other countries, the gallbladder model could not be replicated due to the high cost of tacker and mesh. While in the UK, USA, and Europe about 30%–40% hernia repairs are performed laparoscopically (highest 60% in Germany), in India and China and other Asian countries <5% laparoendoscopic surgery of groin hernia is performed. Unlike laparoscopic cholecystectomy, which can be taught and learned on anesthetized animal, an animal model for TEP is nonexistent. Only TAPP can be simulated on a porcine model. Dry models and virtual simulators have very limited value to teach and learn TEP/TAPP that is where the cadaver training model becomes significant, which gives participants to perform the complete TEP/TAPP independently.

We were harboring a dream for a long time to start a center of excellence for laparoscopic training at the Department of Surgical Disciplines, AIIMS, New Delhi. AIIMS, New Delhi, is the largest teaching and research center not only in India but also in entire South Asia. It has been rated as the world's third-best hospital providing quality tertiary health care at low cost.

I had an opportunity to meet Late Prof. Gerhard Buess (Professor of Surgery and Director, Minimally Invasive Surgery Training Centre, University of Tuebingen, Germany) in July 2006. Actually, Prof. Buess introduced me to Prof. Bittner in July 2006 when I visited Prof. Bittner's Marien Clinic Hospital in Stuttgart and observed him performing TAPP. During my visit to his research center, Prof. Buess expressed his concern about lack of proper structured hands-on skill training in the field of minimal access surgery. The idea of establishing a training center at AIIMS, New Delhi, evolved in Tuebingen. Prof. Buess took up the matter with high-ups in Richard Wolf (Late Mr. Alfons Notheis, MD Richard Wolf) and Erbe. Subsequently, Dr. V. K. Bansal, then Assistant Professor in Surgery, and my associate had an opportunity to visit and work closely with Prof. Buess's Minimally Invasive Surgery Training Centre in the University of Tuebingen, thus maturing the whole process of establishing such a center at AIIMS, New Delhi.

In March 2007, a state of the art Minimally Invasive Surgery Training Centre was established within the Department of Surgical Disciplines, AIIMS. The Richard Wolf provided an educational grant and donated all the equipment and instruments for the training center.The training center was set up in close cooperation of Prof. Buess. The principal objective of the training center was to offer basic and advanced courses for learning operative laparoscopic skills at an affordable cost to practicing surgeons. The courses include laparoscopic cholecystectomy, appendectomy, and techniques of laparoscopic knotting and suturing. These courses are especially designed to impart knowledge and hands-on experience to postgraduate students and senior residents in surgery as well as practicing general surgeons. The course in basic laparoscopic skills is relevant to all the surgical specialties including gynecology, urology, pediatric surgery, surgical oncology, trauma surgery, and gastrointestinal surgery.

The first training course for basic laparoscopic skills was inaugurated on March 26, 2007, by Prof. Buess, Prof. B. M. L. Kapur (former Professor and Head, Department of Surgical Disciplines, AIIMS), and Prof. Mahesh C Misra. Ten participant surgeons were imparted intensive hands-on training in basic laparoscopic skills and endoscopic suturing over 5 days. During the inaugural course of the center, Prof. Buess and his colleague Mrs. Milander themselves demonstrated the handling of instruments, suturing, and knotting on the animal organs. A live workshop was also organized on this occasion where 500 delegates participated.

The demand for participation in the training course has been rising steadily, and the waiting time at present is over 6 months. The hands-on Tuebingen training module has been adjudged by far the best in the world.

Mr. Alfons Notheis, the CEO of Richard Wolf GmbH, Germany, graced the inauguration with his presence and delivered a speech. Mr. Benjamin Seidenspinner, the Product Manager of Surgery, Richard Wolf GmbH, Germany, added color to the occasion by explaining and detailing about Wolf laparoscopic instruments and their applications.

Wolf's active participation indicated that it recognizes the potential market of India where there are vast scope and appreciation for endoscopic instruments. The training center at AIIMS is the first of its kind in Asia. Minimally invasive surgery training centre (mistc), AIIMS, is an enormous opportunity for budding laparoscopic surgeons from all over India and the subcontinent to acquire hands-on training to perfect the technique of laparoscopic surgery.

The training center is equipped with six stations. Each training station has all laparoscopic equipment including a video monitor (Medical LCD 21”), light source (180 W, Xenon, AUTO LP 5123), camera (1 CCD Endocam 5512), telescope (10 mm, 30°), electrocautery machine (ERBE 300s), laparoscopic hand instruments, i.e., trocar (conical tip 5 mm, 10 mm), soft tooth grasping forceps, Maryland dissecting forceps, hook electrode (5 mm), scissors (5 mm, curved), and clip applicator (10 mm).

The trainer has been developed in a form identical to human anatomy. It consists of four parts – fluid reservoir, dorsal abdominal form, abdominal wall, and neoprene cover[17] [Figure 1]. The fluid reservoir is saucer shaped and collects cleaning and organ fluid. It also has an integrated tube for evacuating fluid and a connection for grounding electrocautery. The dorsal abdominal form for integration of animal organs is made of metal net. The form of the net is constructed exactly like the form of human abdominal cavity, so that animal organs can be integrated in a more realistic way and close to human anatomy. The abdominal wall is a metallic wide mesh, and the cover is made out of neoprene. The elasticity of the material is similar to that of the human abdominal wall. The normal ports for laparoscopic surgery can be placed anywhere at will, and surgeons can feel realistic resistance during the insertion of trocar and can manipulate the ports like in a real operation. Thus, the port placement, which constitutes an important step in the training of laparoscopic surgery, can be practiced on this model.
Figure 1: Tuebingen trainer with neoprene cover

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The following courses are held based on this trainer:

  1. Training course in basic operative laparoscopy
  2. Training in laparoscopic hernia
  3. Training in laparoscopic colorectal surgery
  4. Training in laparoscopic suturing skills.

Till date, >200 courses have been held with 124 courses in basic operative laparoscopy and 54 courses in hernia surgery. A total of 2000 participants have been trained including residents, consultants, and private practitioners from various surgical fields (gynecology, general surgery, urology, gastrointestinal surgery, pediatric surgery, surgical oncology, and transplant surgery). Participants have not only been from various parts of India but also abroad from Iraq, China, Iran, Nepal, Bangladesh, Australia, and the USA.

  Training Course in Laparoscopic Hernia Surgery Top

This is an intensive 3-day course designed for surgeons who are well versed in laparoscopic surgery and are ready to undertake advanced laparoscopic procedures. Each course includes a total of six participants. This course lays emphasis on understanding the laparoscopic anatomy of inguinal area, operative demonstration of laparoscopic TEP, TAPP repair, and ventral hernia repair in live operation theater (OT) environment. Video demonstration of various techniques of groin and ventral/incisional hernias with the help of edited and unedited video recordings of the procedures. Various mesh fixation devices for laparoscopic ventral and inguinal hernia repair are demonstrated along with clinical discussion on management of various types of inguinal and ventral hernias. This course also includes working in the wet laboratory for laparoscopic TAPP repair and on lap mentor for laparoscopic ventral hernia repair.

The main objectives of this course are to learn preoperative planning and peroperative management, relevant anatomy, and treatment options with an emphasis on complication prevention and management to improve outcomes in patients with inguinal hernia and ventral hernia and also to understand the management and prevention of complications during laparoscopic TAPP and TEP inguinal hernia repair and the repair of large scrotal hernias.

The course begins with live demonstration in the OT. On the 1st day, there is a live demonstration of both laparoscopic TEP and TAPP of inguinal hernia OT. The second half of the day includes demonstration of intraperitoneal mesh fixation with sutures on a phantom model (porcine abdominal wall) mounted on the MISTC trainer. The participants are then divided into groups of two, and each participant individually performs intraperitoneal onlay mesh fixation using suture technique.

The day 2 is spent entirely in the OT, where, in addition to laparoscopic inguinal hernia repair, there is also demonstration of incisional hernia repair by both tacker and suture fixation techniques. The day 2 then concludes with suturing practice on a cloth model inside the MISTC trainer and a lecture on the laparoscopic anatomy of the inguinal region.

Apart from exposure to live hernia surgeries conducted by experienced surgeons, the participants are given hands-on training on a porcine model (live anesthetized animal) where each participant performs a TAPP repair on either side and also performs an incisional hernia repair. The training is conducted under close supervision of a senior consultant.

Description of model

Live anesthetized male pigs weighing about 35–40 kg are used. A laparoscopic camera system, insufflators, and complete set of laparoscopic instruments are used.


The porcine laparoscopic inguinal anatomy is similar to that of humans barring few differences:

  1. The urinary bladder is intraperitoneal as compared to extraperitoneal location in humans
  2. The peritoneum is very thin
  3. There is a patent processus vaginalis; however, hernia is rarely seen due to the quadruped nature of the animal.

The vascular anatomy and the cord contents are similar to that of humans.


The animal is put under general anesthesia by a veterinary surgeon, in a supine position and adequately strapped. Carbon dioxide pneumoperitoneum is established using a Veress needle through supraumbilical stab wound to achieve an intra-abdominal pressure of 12–14 mmHg. A 10-mm port (Ethicon Endo-Surgery) is then inserted through the same wound, and a 10 mm 0° video telescope is used for endovision. A 10-mm port and a 5-mm port are then introduced laterally at the level of umbilicus.

As the urethra in porcine model is very delicate and cannot be catheterized easily, the bladder is emptied using a Veress needle inserted percutaneously under vision. This step is essential as the bladder, being intraperitoneal, completely obstructs the visualization of the inguinal anatomy.

The peritoneal flap is raised using a grasper and scissors beginning lateral to the inferior epigastric vessels and continuing medially up to the medial umbilical ligament. The inferior flap is raised till the symphysis pubis medially and the psoas laterally. The processus vaginalis is then dissected away from the vas and cord structures and divided. Thus, the triangle of doom is delineated.

A small piece of polypropylene mesh is then placed to cover the area and fixed medially to the symphysis pubis using 10-mm EMS (Ethicon) stapler. The intra-abdominal pressure is then reduced and peritoneum is sutured using 3–0 PDS. A similar procedure is then carried out on the opposite side by the next participant.

  Results Top

From August 2008 to September 2010, 12 courses in laparoscopic inguinal hernia were conducted and included a total of 72 participants. All the participants were male surgeons. The median age was 32 years (range: 25–52 years). The average laparoscopic experience was 3.5 years (range: 1–16 years). All the participants had performed, on an average, 30 laparoscopic procedures (10–100) with laparoscopic cholecystectomy (100%) being the most commonly performed laparoscopic procedure, followed by laparoscopic appendectomy (63%). Only four (6%) had attempted unsatisfactorily laparoscopic inguinal hernia repair prior to the course.

On conducting a postcourse evaluation, feedback from the participant surgeons has been very encouraging. Most surgeons find it relatively easier to perform TAPP as compared to TEP. All the participants had started performing laparoscopic inguinal hernia repair with 38% performing TAPP, 42% performing TEP, and 20% performing both. Even those who had been performing laparoscopic inguinal hernia repair prior to participation in the course reported significant improvement in their technique and skills. None of the participants has experienced any major complication or recurrence till date. We firmly believe that a PP model will work very effectively for the teaching and learning of laparoendoscopic hernia surgery.

  Cadaveric Model Is the Best! Top

Advantages of cadaveric model are obvious, realistic human anatomy. Operative steps of both TEP and TAPP can be taught and learned by performing the complete procedure starting from creation of pneumoperitoneum [Figure 2]a, dissection of preperitoneal space [Figure 2]b with delineation of anatomy beautifully, mesh placement and orientation [Figure 2]c, and finally, suture closure (Bittner technique) [Figure 2]d.
Figure 2: (a) Pneumoperitoneum creation in a cadaver. (b) Transabdominal preperitoneal dissection. (c) Mesh placement in transabdominal preperitoneal repair cadaver model. (d) Suture closure of peritoneal flaps after mesh placement

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  Summary Top

Adoption and adaptation of laparoendoscopic repair of groin hernia has been slow over the past 25 years of development of minimally invasive surgery worldwide. However, penetration of laparoscopic incisional and ventral hernia has been higher among surgeons globally. The reasons for slow progress have been primarily due to lack of opportunities for practicing surgeons to obtain satisfactory hands-on training in laparoendoscopic techniques in all geographic regions, for example, American continent, Europe, and Australasia including China and India (two large nations). In India, another significant and important factor has been the higher cost of laparoscopic hernia repair for both groin and incisional and ventral hernias.

We hope that with the increasing opportunities for hands-on training, there will be more enthusiasm and eagerness to teach and learn laparoendoscopic techniques of hernia techniques. We appeal to all senior laparoendoscopic expert surgeons to encourage and be prepared to accept practicing young surgeons for hands-on training through PP model. PP model creates a safe, cost-effective, and friendly learning environment. PP model provides one-to-one mentoring opportunities for those willing to go an extra mile for the benefit of their patients. Patients from underserved geographic regions deserve the advantages of newer techniques irrespective of their economic background. The International Endohernia Society (IEHS) is making all-out efforts under the dynamic leadership of Prof. Reinhard Bittner and Prof. Ferdinand Kockerling with all the members of IEHS. Efforts are on for standardization of hernia training through accredited hernia centers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS 2001;5:89-94.  Back to cited text no. 1
Mouret P. How I developed laparoscopic cholecystectomy. Ann Acad Med Singapore 1996;25:744-7.  Back to cited text no. 2
Blum CA, Adams DB. Who did the first laparoscopic cholecystectomy? J Minim Access Surg 2011;7:165-8.  Back to cited text no. 3
Dubois F, Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy. Preliminary report of 36 cases. Ann Surg 1990;211:60-2.  Back to cited text no. 4
Udwadia TE. Laparoscopy in India – A personal perspective. J Minim Access Surg 2005;1:51-2.  Back to cited text no. 5
Chellappa M. Laparoscopic cholecystectomy. Singapore Med J 1993;34:199-200.  Back to cited text no. 6
Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy. The new 'gold standard'? Arch Surg 1992;127:917-21.  Back to cited text no. 7
Katkhouda N. Laparoscopic treatment of gastroesophageal reflux disease – Defining a gold standard. Surg Endosc 1995;9:765-7.  Back to cited text no. 8
Friedman RL, Fallas MJ, Carroll BJ, Hiatt JR, Phillips EH. Laparoscopic splenectomy for ITP. The gold standard. Surg Endosc 1996;10:991-5.  Back to cited text no. 9
Payne JH Jr., Tashima W, Lapschies B, Washecka R, Hariharan A, Duh QY. Advanced laparoscopy: “the next generation”. The adrenal, kidney, spleen, pancreas, and liver. Hawaii Med J 1998;57:710-4.  Back to cited text no. 10
Tetik C, Arregui ME, Dulucq JL, Fitzgibbons RJ, Franklin ME, McKernan JB, et al. Complications and recurrences associated with laparoscopic repair of groin hernias. A multi-institutional retrospective analysis. Surg Endosc 1994;8:1316-22.  Back to cited text no. 11
Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr., Dunlop D, Gibbs J, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819-27.  Back to cited text no. 12
Strate T, Mann O, Izbicki JR. Open mesh versus laparoscopic mesh hernia repair. N Engl J Med 2004;351:1463-5.  Back to cited text no. 13
Ferzli G, Sayad P, Huie F, Hallak A, Usal H. Endoscopic extraperitoneal herniorrhaphy. A 5-year experience. Surg Endosc 1998;12:1311-3.  Back to cited text no. 14
Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia repair: Lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc 2009;23:482-6.  Back to cited text no. 15
Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ. Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 2002;89:1062-6.  Back to cited text no. 16
Bansal VK, Panwar R, Misra MC, Bhattacharjee HK, Jindal V, Loli A, et al. Are short-term focused training courses on a phantom model using porcine gall bladder useful for trainees in acquiring basic laparoscopic skills? Surg Laparosc Endosc Percutan Tech 2012;22:154-60.  Back to cited text no. 17


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