Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis

UMMS Affiliation

Department of Surgery

Publication Date


Document Type



Biomedical Devices and Instrumentation | Pathological Conditions, Signs and Symptoms | Surgery | Surgical Procedures, Operative


PURPOSE: rTAPP-VHR is a novel technique which may be added to a surgeon's armamentarium. We aim to evaluate the robotic transabdominal preperitoneal ventral hernia repair (rTAPP-VHR) learning curve based on operative times while accounting for peritoneal flap integrity.

METHODS: We performed a retrospective analysis of a database collected over a 7-year period. Patients with primary ventral hernias were included and a cumulative sum analysis(CUSUM) was used to create learning curves for three subsets of operative times. A risk-adjusted CUSUM (RA-CUSUM) accounted for repair quality based on peritoneal flap completeness. The flap was considered as incomplete when peritoneal gaps were unable to be closed.

RESULTS: 105 patients undergoing rTAPP-VHR were included. Learning curves were created for skin-to-skin, console, and off-console times. Patients were divided into three phases. In terms of skin-to-skin times, both phase 2 and 3 had a mean 11 min shorter than that of phase 1 (p = 0.0498, p = 0.0245, respectively), with a steady decrease after forty-six cases. An incomplete peritoneal flap was noted in 25/36 patients in phase 1, as compared to 5/24 and 5/45 patients in phase 2and3, respectively. When risk-adjusted for peritoneal flap completeness, gradually decreasing skin-to-skin times were observed after sixty-one cases. In terms of off-console times, the mean across three phases was 14 min, with marked improvement after forty-three cases.

CONCLUSIONS: Forty-six cases were needed to achieve steadily decreasing operative times. We can assume that ensuring good-quality repairs, through maintenance of peritoneal flap integrity, was gradually improved after sixty-one cases. Moreover, familiarization with port placements and robotic docking was accomplished after forty-three cases.


Learning curve, Robotic ventral hernia repair, TAPP, Transabdominal preperitoneal

DOI of Published Version



Kudsi OY, Gokcal F, Bou-Ayash N, Crawford AS, Chung SK, Chang K, Litwin D. Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis. Hernia. 2020 Jun 3:1–10. doi: 10.1007/s10029-020-02228-0. Epub ahead of print. PMID: 32495055; PMCID: PMC7268975. Link to article on publisher's site

Journal/Book/Conference Title

Hernia : the journal of hernias and abdominal wall surgery

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Link to Article in PubMed

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