Abstract

Introduction: Laparoscopic inguinal hernia repair has evolved from a controversial and slowly adopted procedure to an established approach with recognized advantages. Increasing experience has progressively expanded its indications, including acute irreducible and strangulated groin hernias. However, although current guidelines support emergency laparoscopy in selected patients when appropriate expertise and resources are available, the evidence defining when a laparoscopic procedure should be abandoned and converted remains limited. Objective: To review the historical evolution and current evidence regarding laparoscopic management of complicated inguinal hernia, with particular emphasis on the indications for conversion, and to propose a practical decision-making framework based on surgical judgment and patient safety. Methods: A narrative review of international guidelines, systematic reviews, metaanalyses, and relevant observational studies on emergency laparoscopic groin hernia repair was performed, with particular attention to conversion, difficult reduction, bowel viability and resection, contamination, mesh use, and cognitive factors influencing intraoperative decision-making. A historical operative experience from the early laparoscopic era is used to illustrate the evolution of surgical judgment. Results: Current evidence supports laparoscopic repair as a feasible option in selected patients with complicated groin hernias, but the certainty of evidence is predominantly low or very low. No validated time limit, number of reduction attempts, conversion score, or other objective threshold defines when conversion should occur. Failure to achieve safe reduction is a documented reason for conversion, whereas bowel injury, necrosis, or the need for intestinal resection do not necessarily mandate conversion if they can be managed safely. Based on the available evidence and surgical safety principles, three conditions are proposed for continued laparoscopic management: adequate Vision, maintained Control, and meaningful Progress, all subordinated to Patient Safety. Cognitive biases, including overconfidence, fixation, and persistence with an unsuccessful strategy, may also influence the decision to convert. Conclusion: Emergency laparoscopic repair is a reasonable option for selected complicated groin hernias, but the precise threshold for conversion remains insufficiently defined by current evidence. Loss of adequate vision, control, or meaningful progress should prompt reassessment, with patient safety as the overriding criterion. Conversion should be regarded as a safety strategy rather than technical failure.

Keywords

inguinal hernia, laparoscopy, TAPP, strangulated hernia, conversion, surgical judgment, patient safety, cognitive bias