Improving Intraoperative Compliance With Critical View of the Myopectineal Orifice Criteria Using the V-M Pathway During Laparoscopic Inguinal Hernia Repair.

Abstract

Background: The CVMPO criteria were developed to standardize critical quality steps during laparoscopic inguinal hernia repair. However, consistent intraoperative compliance remains challenging, particularly during prolonged or technically difficult procedures, or under cognitive fatigue. Checklist-based approaches may be difficult to recall and apply in real time.

Methods: A prospective observational study included 211 consecutive laparoscopic inguinal hernia repairs performed using a standardized technique. An original spatial cognitive framework, the V-M Pathway, mapping CVMPO criteria onto the laparoscopic view of the inguinal region, was applied as a deliberate intraoperative pause before mesh placement. Time required to verbally recall all nine CVMPO criteria was measured intraoperatively. All procedures were routinely recorded in full from the beginning to the end of the operation. Surgeon-identified corrective actions prompted by CVMPO recall were documented during the procedure. The time required to implement corrective actions was determined postoperatively based on independent review of the complete operative video recordings. All procedures underwent post hoc video verification to confirm objective adherence to the CVMPO criteria.

Results: Complete recall of all nine CVMPO criteria using the V-M Pathway was achieved in all procedures, with a median recall time of 58 s (IQR 52-64). Intraoperative recall prompted corrective actions in 20.4% of cases. Among procedures requiring corrective actions, the median time required to complete all corrections was 46 s (IQR 38-81). Independent video review confirmed complete adherence to all CVMPO criteria in 97.2% of procedures. Mesh placement was performed only after CVMPO confirmation in all cases.

Conclusion: The V-M Pathway supported rapid intraoperative recall of CVMPO criteria, prompted timely corrective actions, and was associated with high video-verified adherence to predefined quality criteria. Importantly, the additional time required for recall and corrective actions represented only a small fraction of total operative time, suggesting that integration of the pathway is feasible without major workflow disruption. This simple spatial cognitive aid may support intraoperative verification of quality criteria during laparoscopic inguinal hernia repair without disrupting operative workflow.