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    Decoding surgical proficiency and complexity: A machine learning framework for robotic herniorrhaphy
    (Springer Nature Link, 2025) Shin, Thomas H.; Fanta, Abeselom; Gökçal, Fahri; Shields, Mallory; Benlice, Çiğdem; Kudsi, Omar Yusef
    Objective To evaluate the predictive value of objective performance indicators (OPIs) for case complexity assessment and explore their role in quantifying skill acquisition during robotic ventral herniorrhaphy. Summary background data Despite advances in herniorrhaphy techniques, unclear metrics of case complexity have signifi cant implications for operative planning, resource allocation, and patient outcomes. While existing complexity definitions rely primarily on clinical factors external to operator behavior, the expanding adoption of robotic platforms in ventral her nia repair provides unprecedented access to quantifiable surgical performance metrics. However, the relationship between these objective performance indicators and both case complexity and skill development remains incompletely understood, representing a gap that machine learning approaches may help address. Methods OPI and clinical data from 561 consecutive robotic ventral hernia repairs over eight years were analyzed using iterative ensemble machine learning models to predict case complexity. Dimensional reduction analyses using t-distributed stochastic neighbor embedding tracked skill evolution, with Euclidean distances calculated between successive cases to quantify skill acquisition over time. Results Gradient boosting models integrating clinical and OPI variables achieved F1 score of 0.87, while OPIs alone scored 0.58. Longitudinal analysis revealed high OPI variability during early cases, stabilizing within 10 months despite increas ing case complexity, indicating skill acquisition may compensate for procedural difficulty. Dimensional reduction analyses captured this evolution through weighted Euclidean distances. Conclusions Objective performance indicators poorly predict case complexity independently, yet their temporal evolution reveals surgical skill acquisition. The concurrent stabilization of OPI stochasticity and progression to more complex cases demonstrates that surgical proficiency and complexity assessment are interdependent phenomena, establishing digital metrics as tools for understanding the dynamic relationship between surgeon learning and case difficulty.
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    Robotic eTEP-TAR abdominal wall reconstruction for complex post liver transplant incisional hernia with concomitant inguinal hernia repair: A video vignette
    (Springer Nature Link, 2026) Bayrakçeken, Serra; Benlice, Çigdem; Aghayeva, Afag; Kudsi, Omar Yusef; Baca, Bilgi
    Introduction Complex incisional hernias after major upper abdominal surgery are technically challenging because of altered anatomical planes, multiple fascial defects, and expected adhesions. Robotic enhanced-view totally extraperitoneal repair with transversus abdominis release may provide a minimally invasive option for selected patients by enabling retromuscular dissection, fascial closure, and wide extraperitoneal mesh reinforcement while limiting intraperitoneal manipulation. Case presentation This video vignette presents an 84-year-old man with multiple incisional hernia defects along a previous Mercedes incision after liver transplantation and a concomitant left direct inguinal hernia. Preoperative imaging demon strated a wide subxiphoid abdominal wall defect and a fat-containing left inguinal hernia. Surgical technique A robotic eTEP-TAR approach was performed. Bilateral retromuscular dissection was completed, the inguinal and incisional hernia contents were reduced, and bilateral transversus abdominis release was performed to facilitate medial fascial advancement and lateral extension of the working space. The fascial and peritoneal defects were closed intra corporeally, and wide mesh reinforcement was achieved using a 30 × 30 cm polypropylene mesh, with additional meshes placed for the inguinal and lower quadrant defects. The postoperative course was uneventful, and the patient was discharged on postoperative day 2. At postoperative day 7 follow-up, he had no complaints, and the wounds were clean. Conclusion This case demonstrates the feasibility of robotic eTEP-TAR abdominal wall reconstruction with concomitant inguinal hernia repair in a selected post-transplant patient with complex abdominal wall defects.