Inguinal hernia repair: is there a benefit to using the robot?

Short-term outcomes and inflammatory stress response following laparoscopy or robotic-assisted transabdominal preperitoneal inguinal hernia repair (TAPP): study protocol for a prospective, randomized trial (ROLAIS)

BACKGROUND

Inguinal hernia repair is a frequently performed surgical procedure, with laparoscopic repair emerging as the preferred approach due to its lower complication rate and faster recovery compared to open repair. Mesh-based tension-free repair is the gold standard for both methods. In recent years, robotic hernia repair has been introduced as an alternative to laparoscopic repair, offering advantages such as decreased postoperative pain and improved ergonomics. This study aims to compare the short- and long-term outcomes, including the surgical stress response, postoperative complications, quality of life, and sexual function, between robotic-assisted transabdominal preperitoneal (rTAPP) and laparoscopic TAPP inguinal hernia repairs.

METHODS

This randomized controlled trial will involve 150 patients from the Surgical Department of the University Hospital of Southern Denmark, randomized to undergo either rTAPP or laparoscopic TAPP. Surgical stress will be quantified by measuring C-reactive protein (CRP) and cytokine levels. Secondary outcomes include complication rates, quality of life, sexual function, and operative times. Data analysis will adhere to the intention-to-treat principle and will be conducted once all patient data are collected, with outcomes assessed at various postoperative intervals.

DISCUSSION

This study holds significance in evaluating the potential advantages of robotic-assisted surgery in the context of inguinal hernia repairs. It is hypothesized that rTAPP will result in a lower surgical stress response and potentially lower the risk of postoperative complications compared to conventional laparoscopic TAPP. The implications of this research could influence future surgical practices and guidelines, with a focus on patient recovery and healthcare costs. The findings of this study will contribute to the ongoing discourse surrounding the utilization of robotic systems in surgery, potentially advocating for their broader implementation if the benefits are substantiated.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05839587. Retrospectively registered on 28 February 2023.

Economic analysis of the robotic approach to inguinal hernia versus laparoscopic: is it sustainable for the healthcare system?

INTRODUCTION

There has been a rapid proliferation of the robotic approach to inguinal hernia, mainly in the United States, as it has shown similar outcomes to the laparoscopic approach but with a significant increase in associated costs. Our objective is to conduct a cost analysis in our setting (Spanish National Health System).

MATERIALS AND METHODS

A retrospective single-center comparative study on inguinal hernia repair using a robotic approach versus laparoscopic approach.

RESULTS

A total of 98 patients who underwent either robotic or laparoscopic TAPP inguinal hernia repair between October 2021 and July 2023 were analyzed. Out of these 98 patients, 20 (20.4%) were treated with the robotic approach, while 78 (79.6%) underwent the laparoscopic approach. When comparing both approaches, no significant differences were found in terms of complications, recurrences, or readmissions. However, the robotic group exhibited a longer surgical time (86 ± 33.07 min vs. 40 ± 14.46 min, p < 0.001), an extended hospital stays (1.6 ± 0.503 days vs. 1.13 ± 0.727 days, p < 0.007), as well as higher procedural costs (2318.63 ± 205.15 € vs. 356.81 ± 110.14 €, p < 0.001) and total hospitalization costs (3272.48 ± 408.49 € vs. 1048.61 ± 460.06 €, p < 0.001). These results were consistent when performing subgroup analysis for unilateral and bilateral hernias.

CONCLUSIONS

The benefits observed in terms of recurrence rates and post-surgical complications do not justify the additional costs incurred by the robotic approach to inguinal hernia within the national public healthcare system. Nevertheless, it represents a simpler way to initiate the robotic learning curve, justifying its use in a training context.

Comparing Robot-Assisted and Laparoscopic Inguinal Hernia Repair: A Systematic Review and Meta-Analysis

Inguinal hernia repair is a common surgical intervention. Advancements in minimally invasive techniques, specifically laparoscopic (LR) and robot-assisted (RR) approaches, have reshaped the landscape of surgical options. This meta-analysis aimed to systematically assess and compare the effectiveness and safety of laparoscopic and robot-assisted inguinal hernia repair through a comprehensive review of the literature. A systematic search of databases was conducted to identify relevant studies published up to November 30, 2023. Fifteen studies, encompassing a total of 64,568 participants, met the inclusion criteria. Pooled estimates for key outcomes, including duration of operation, overall complications, and surgical site infection (SSI), were calculated using random-effects models. This meta-analysis revealed a statistically significant difference in the duration of surgery, favoring laparoscopic repair over robot-assisted techniques (mean difference: 26.85 minutes, 95% CI (1.16, 52.54)). Overall complications did not significantly differ between the two approaches (odds ratio: 1.54, 95% CI (0.83, 2.85)). However, a significantly greater risk of SSI was identified for robot-assisted procedures (odds ratio: 3.32, 95% CI (2.63, 4.19)). This meta-analysis provides insights into the comparative effectiveness of laparoscopic and robot-assisted inguinal hernia repair. While laparoscopy has shorter operative times and comparable overall complication rates, the increased risk of SSI during robot-assisted procedures necessitates careful consideration in clinical decision-making. Surgeons and healthcare providers should weigh these findings according to patient characteristics, emphasizing a personalized approach to surgical decision-making. The evolving landscape of inguinal hernia repair warrants ongoing research to refine techniques and optimize outcomes for the benefit of patients undergoing these procedures.

Current trends and outcomes for unilateral groin hernia repairs in the United States using the Abdominal Core Health Quality Collaborative database: A multicenter propensity score matching analysis of 30-day and 1-year outcomes

BACKGROUND

Different unilateral groin hernia repair approaches have been developed in the last 2 decades. The most commonly done approaches are open inguinal hernia repair by the Lichenstein technique, laparoscopic approach by either total extraperitoneal or transabdominal preperitoneal, and robotic transabdominal preperitoneal approach. Hence, this study aimed to compare early and late postoperative outcomes in patients who underwent unilateral robotic transabdominal preperitoneal, laparoscopic transabdominal preperitoneal, and laparoscopic total extraperitoneal, and open groin hernia repair using a United States national hernia database, the Abdominal Core Health Quality Collaborative Database.

METHODS

Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent elective unilateral groin hernia repair from 2015 to 2022, with a 1:1 propensity score match analysis conducted for balanced groups. The univariate analysis compared the groups across the preoperative, intraoperative, and postoperative timeframes.

RESULTS

The Abdominal Core Health Quality Collaborative database identified 14,320 patients who underwent elective unilateral groin hernia repair and had documented 30 days of follow-up. Propensity score matching stratified 1,598 patients to each group (total of 6,392). The median age was 64 years (interquartile range 53-74) for open groin hernia repair, whereas 60 (interquartile range 47-69) for laparoscopic transabdominal preperitoneal, 62 (interquartile range 48-70) for laparoscopic total extraperitoneal, and 60 (interquartile range 47-70) for robotic transabdominal preperitoneal were noted. Open groin hernia repair had more American Society of Anesthesiologists score 4 (52, 3%) patients (P < .001). A painful bulge was the most common indication (>85%). Operating room time >2 hours was more significant in the robotic transabdominal preperitoneal group (123, 8%; P < .001). Seroma rate was higher in the laparoscopic transabdominal preperitoneal (134, 8%; P < .001). A 1-year analysis had 1,103 patients. Hematoma, surgical site infection, readmission, reoperation, and hernia recurrence at 30 days or 1 year did not differ, with an overall recurrence rate of 6% (n = 67) at 1 year (P = .33). In patients with body mass index ≥30 kg/m2, the robotic approach had lower rates of surgical site occurrence (n = 12, 4%; P = .002) and seroma (n = 5, 2%; P < .001) compared with the other groups. When evaluating recurrence 1 year after surgery, the robotic transabdominal preperitoneal group had 10% versus 18% open groin hernia repair, 11% laparoscopic transabdominal preperitoneal, and 18% laparoscopic total extraperitoneal, but it was not statistically significant (P = .53).

CONCLUSION

There was no difference in readmission, reoperation, and surgical site infection among the surgical techniques at 30 days. However, laparoscopic transabdominal preperitoneal was associated with more seromas. Hernia recurrence at 1 year was similar across groups; the robotic approach had the lowest recurrence rate among all 3 repairs but did not reach statistical significance. The robotic approach performed better in patients with a body mass index of 30 kg/m2 for surgical site occurrence and seroma than in other surgical techniques.

Robotic surgery for inguinal and ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis assessed the effectiveness of robotic surgery compared to laparoscopy or open surgery for inguinal (IHR) and ventral (VHR) hernia repair.

METHODS

PubMed and EMBASE were searched up to July 2022. Meta-analyses were performed for postoperative complications, surgical site infections (SSI), seroma/hematoma, hernia recurrence, operating time (OT), intraoperative blood loss, intraoperative bowel injury, conversion to open surgery, length of stay (LOS), mortality, reoperation rate, readmission rate, use of opioids, time to return to work and time to return to normal activities.

RESULTS

Overall, 64 studies were selected and 58 were used for pooled data analyses: 35 studies (227 242 patients) deal with IHR and 32 (158 384 patients) with VHR. Robotic IHR was associated with lower hernia recurrence (OR 0.54; 95%CI 0.29, 0.99; I2: 0%) compared to laparoscopic IHR, and lower use of opioids compared to open IHR (OR 0.46; 95%CI 0.25, 0.84; I2: 55.8%). Robotic VHR was associated with lower bowel injuries (OR 0.59; 95%CI 0.42, 0.85; I2: 0%) and less conversions to open surgery (OR 0.51; 95%CI 0.43, 0.60; I2: 0%) compared to laparoscopy. Compared to open surgery, robotic VHR was associated with lower postoperative complications (OR 0.61; 95%CI 0.39, 0.96; I2: 68%), less SSI (OR 0.47; 95%CI 0.31, 0.72; I2: 0%), less intraoperative blood loss (- 95 mL), shorter LOS (- 3.4 day), and less hospital readmissions (OR 0.66; 95%CI 0.44, 0.99; I2: 24.7%). However, both robotic IHR and VHR were associated with significantly longer OT compared to laparoscopy and open surgery.

CONCLUSION

These results support robotic surgery as a safe, effective, and viable alternative for IHR and VHR as it can brings several intraoperative and postoperative advantages over laparoscopy and open surgery.

A cost-conscious establishment of a robotic abdominal wall reconstruction program in a publicly funded healthcare system

PURPOSE

Despite reports of better short-term outcomes, the main criticism for the adoption of the robotic surgery platform for abdominal wall reconstruction (AWR) has been the associated cost, especially in countries with a publicly funded healthcare system such as Canada. We describe our experience in implementation of robotic AWR while ensuring cost-effectiveness.

METHODS

This is a retrospective cohort analysis of all patients with ventral hernias ranging between 5 to 15 cm who underwent either open or robotic AWR between January 2020 to August 2022. We reviewed patient characteristics, operative time, post-operative length of stay (LOS), and average cost of surgery.

RESULTS

45 patients underwent open repair and 28 underwent robotic repair in the study period. There was no difference in major patient characteristics between the two groups. Operative time was shorter for open repairs (233.2 ± 96.6 min vs. 299.3 ± 71.8 min, p < 0.001). LOS was significantly longer for open repairs (5 days (interquartile range = 4-6) vs. 2 days (IQR = 1.75-3), p < 0.001) and there were significantly more patients who underwent robotic repair who left hospital in less than 3 days (13.3 vs. 64.3%, p < 0.001). The average overall hospital-based cost for each open repair was $26,952.18 when the cost for equipment, operative time, inpatient hospital stay, and epidural use are accounted for, compared to $17,447.40 for robotic repair ($9,504.78 saving per case).

CONCLUSION

With proper selection of patients based on size of hernia, we demonstrate cost conscious adaptation of the robotic technology to AWR. Our future studies will continue to explore the benefits and limits of this approach in complex hernia repair.

Robotic versus laparoscopic transabdominal preperitoneal (TAPP) approaches to bilateral hernia repair: a multicenter retrospective study using propensity score matching analysis

BACKGROUND

Since the introduction of minimally invasive surgery, new techniques like transabdominal preperitoneal (TAPP) repair have progressively gained acceptance for the treatment of groin hernia. Laparoscopic TAPP (LTAPP) is recommended for bilateral repairs. Likewise, the introduction of robotic platforms has promised additional surgical benefits for robotic TAPP (RTAPP), which are yet to be confirmed. This study compared multicenter data obtained from patients undergoing bilateral inguinal hernia repair with RTAPP, performed during the preliminary learning curve period, versus conventional LTAPP.

MATERIALS AND METHODS

All consecutive bilateral inguinal hernia patients from four Italian centers between June 2015 and July 2020 were selected. A propensity score model was used to compare patients treated with LTAPP versus RTAPP, considering sex, age, body mass index, current smoking status, overall comorbidity, hernia classification (primary or recurrent), and associated procedures as covariates. After matching, intraoperative details and postoperative outcomes were evaluated.

RESULTS

In total, 275 LTAPP and 40 RTAPP were performed. After matching, 80 and 40 patients were allocated to the LTAPP and RTAPP cohorts, respectively. No intraoperative complications or conversion to open surgery occurred. However, a longer operative time was recorded in the RTAPP group (79 ± 21 versus 98 ± 29 min; p < 0.001). Postoperative visual analog scale (VAS) pain scores (p = 0.13) did not differ and complication rates were similar. There were no clinical recurrences in either group, with mean follow-up periods of 52 ± 14 (LTAPP) and 35 ± 8 (RTAPP) months. A statistical difference in length of hospital stay was found between the groups (1.05 ± 0.22 vs 1.50 ± 0.74 days; p < 0.001).

CONCLUSION

In this patient population, outcomes for bilateral inguinal hernia repair appear comparable for RTAPP and LTAPP, except for a shorter recovery after laparoscopic surgery. A longer operative time for robotic surgery could be attributable to the learning curve period of each center.

Laparoscopic versus robotic inguinal hernia repair: a single-center case-matched study

INTRODUCTION

Robotic inguinal hernia repair (RIHR) is becoming increasingly common and is the minimally invasive alternative to laparoscopic inguinal hernia repair (LIHR). Thus far, there is little data directly comparing LIHR and RIHR. The purpose of this study will be to compare outcomes for LIHR and RIHR at a single center.

METHODS

A prospective institutional hernia database was queried for patients who underwent transabdominal LIHR or RIHR from 2012 to 2020. The patients were then matched based on the surgeon performing the operation (single, expert hernia surgeon) and laterality of repair. Standard descriptive statistics were used.

RESULTS

There were 282 patients who met criteria for the study, 141 LIHR and 141 RIHR; 32.6% of patients in each group had a bilateral repair (p = 1.00). LIHR patients were slightly younger (54.4 ± 15.6 vs 58.6 ± 13.8; p = 0.03) but similar in terms of BMI (27.1 ± 5.1 vs 29.1 ± 2.1; p = 0.70) and number of comorbidities (2.9 ± 2.5 vs 2.6 ± 2.2; p = 0.59). Operative time was found to be longer in the RIHR group, but when evaluating RIHR at the beginning of the study versus the end of the study, there was a 50-min decrease in operative time (p < 0.01). Recurrence rates were low for both groups (0.7% vs 1.4%; p = 0.38) with mean follow-up time 13.0 ± 13.3 months. There was only one wound infection, which was in the robotic group. No patients required return to the operating room for complications relating to their surgery. There were no 30-day readmissions in the LIHR group and three 30-day readmissions in the RIHR group (p = 0.28).

CONCLUSION

LIHR and RIHR are both performed with low morbidity and have comparable overall outcomes. The total charges were increased in the RIHR group. Either LIHR or RIHR may be considered when performing inguinal hernia repair and should depend on surgeon and patient preference; continued evaluation of the outcomes is warranted.

Minimally Invasive Repair of Recurrent Inguinal Hernia: Multi-Institutional Retrospective Comparison of Robotic Versus Laparoscopic Surgery

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

Robot-assisted groin hernia repair is primarily performed by specialized surgeons: a scoping review

Surgical residents routinely participate in open and laparoscopic groin hernia repairs. The increasing popularity of robot-assisted groin hernia repair could lead to an educational loss for residents. We aimed to explore the involvement of surgical specialists and surgical residents, i.e., non-specialists, in robot-assisted groin hernia repair. The scoping review was reported according to PRISMA-ScR guideline. A protocol was uploaded at Open Science Framework, and a systematic search was conducted in four databases: PubMed, EMBASE, Cochrane CENTRAL, and Web of Science. Included studies had to report on robot-assisted groin hernia repairs. Data charting was conducted in duplicate. Of the 67 included studies, 85% of the studies described that the robot-assisted groin hernia repair was performed by a surgical specialist. The rest of the studies had no description of the primary operating surgeon. Only 13% of the included studies reported that a resident attended the robot-assisted groin hernia repair. Thus, robot-assisted groin hernia repair was mainly performed by surgical specialists, and robot-assisted groin hernia repair therefore seems to be underutilized to educate surgical residents.

Effect of ketorolac tromethamine combined with dezocine prior administration on hemodynamics and postoperative analgesia in patients undergoing laparoscopic hernia repair

OBJECTIVE

To observe the effect of Ketorolac tromethamine combined with dezocine prior administration on hemodynamics and postoperative sedation in patients undergoing laparoscopic hernia repair.

METHODS

100 male patients aged 60 to 80 years old, a line to elective laparoscopic inguinal hernia repair, were randomly divided into four groups: control group (Group A) and dezocine group (Group B), ketorolac tromethamine group (Group C), ketorolac tromethamine combined with dezocine group (Group D). Patients were administrated with 0.1 mg/kg dezocine in Group B, 0.5 mg/kg ketorolac in Group C, 0.1 mg/kg dezocine, and 0.5 mg/kg ketorolac in Group D, and with an equal dose of normal saline in group A. The heart rate (HR) and mean arterial pressure (MAP) of patients in 4 groups were recorded at each time point as follows, T0 (enter the operating room), T1 (before skin resection), 10 min after pneumoperitoneum (T2), mesh placement (T3), and laryngeal mask extraction (T4). Operation time, awakening time (time from drug withdrawal to consciousness recovery), the dosage of propofol, sufentanil, remifentanil, and intraoperative vasoactive drug dosage were recorded to compare. Visual analog scale score and sedation Ramsay score were evaluated 1, 6, 12, and 24 hours after extubation.

RESULTS

There was no significant difference in operation time, anesthesia recovery time, sufentanil dosage, and vasoactive drugs among all groups. The amount of propofol in Group B and D was less than that in Group A and C (P < .05), and there was no difference between Group B and D, A and C (P > .05). The amount of remifentanil in Group B, C, and D was less than that in Group A (P < .05), and Group D was less than B and C (P < .05). After extubation, HR and MAP were significantly higher than before (P < .05). Compared with T0, HR and MAP increased in each group at T4, but MAP and HR in Group D increased the least (P < .05). There were significant differences between Group B, C, D, and A, MAP and HR fluctuated little during extubation (P < .05), but there was a significant difference between Group D and B, C (P < .05). Visual analog scale scores of Group B, C, and D were lower than those of A at 1, 6, and 12 hours after surgery (P < .05), and there was a significant difference between Group D, and B, C (P < .05). Ramsay scores in Group B and D were higher than those in A and C at 1 and 6 hours after the operation (P < .05). There was no difference in the incidence of adverse reactions among groups.

CONCLUSION

The prophylactic use of ketorolac tromethamine and dezocine before laparoscopic inguinal hernia repair can reduce hemodynamic disorder during anesthesia recovery, increase postoperative sedative and analgesic effects.

Spin is present in the majority of articles evaluating robot-assisted groin hernia repair: a systematic review

BACKGROUND

The number of scientific articles published each year is increasing, resulting in greater competition to get work published. Spin is defined as specific reporting strategies used to distort the readers' interpretation of results so that they are viewed more favorable. However, prevalence of spin in studies comparing robot-assisted groin hernia repair with traditional methods is unknown.

OBJECTIVES/AIM

To determine the frequency and extent of spin in studies assessing robot-assisted groin hernia repair.

METHODS

This systematic review was reported according to PRISMA guidelines, and a protocol was registered at PROSPERO before data extraction. Database search included PubMed, EMBASE, and Cochrane Central.

RESULTS

Of 35 included studies, spin was present in 57%. Within these, 95% had spin present in the abstract and 80% in the conclusion of the article. There was no association between study size and spin (p > 0.05). However, presence of spin in studies positively minded towards robot-assisted hernia repair was higher (p < 0.001) compared with those against or being neutral in their view of the procedure. Furthermore, being funded by or receiving grants from Intuitive Surgical were associated with a higher prevalence of spin (p < 0.05) compared with those who were not.

CONCLUSION

Spin was found to be common in articles reporting on robot-assisted groin hernia repair, and presence of spin was higher in studies funded by or receiving grants from the robot company. This suggests that readers should be cautious when reading similar literature.

Current status and future perspectives of robotic inguinal hernia repair

With more than 5500 da Vinci Surgical System (DVSS) installed worldwide, the robotic approach for general surgery, including for inguinal hernia repair, is gaining popularity in the USA. However, in many countries outside the USA, robotic surgery is performed at only a few advanced institutions; therefore, its advantages over the open or laparoscopic approaches for inguinal hernia repair are unclear. Several retrospective studies have demonstrated the safety and feasibility of robotic inguinal hernia repair, but there is still no firm evidence to support the superiority of robotic surgery for this procedure or its long-term clinical outcomes. Robotic surgery has the potential to overcome the disadvantages of conventional laparoscopic surgery through appropriate utilization of technological advantages, such as wristed instruments, tremor filtering, and high-resolution 3D images. The potential benefits of robotic inguinal hernia repair are lower rates of complications or recurrence than open and laparoscopic surgery, with less postoperative pain, and a rapid learning curve for surgeons. In this review, we summarize the current status and future prospects of robotic inguinal hernia repair and discuss the issues associated with this procedure.

Controversies in Inguinal Hernia

Inguinal hernias represent one of the most common pathologic conditions presenting to the general surgeon. In surgical practice, several controversies persist: when to operate, the utility of a laparoscopic versus open approach, the applicability of robotic surgery, the approach to bilateral hernias, management of athletic-related groin pain ("sports hernia"), and the role of tissue-based repairs in modern hernia surgery. Ideally, surgeons should approach each patient individually and tailor their approach based on patient factors and preferences. The informed consent process is critical, especially given increasing recognition of the risk of long-term chronic pain following hernia repair.

Robotic versus laparoscopic inguinal hernia repair: an updated systematic review and meta-analysis

The aim of this study was to review the latest evidence on the robotic approach (RHR) for inguinal hernia repair comparing the pooled outcome of this technique with those of the standard laparoscopic procedure (LHR). A systematic literature search was performed in PubMed, Web of Science and Scopus for studies published between 2010 and 2021 concerning the comparison between RHR versus LHR. After screening 582 articles, 9 articles with a total of 64,426 patients (7589 RHRs) were eligible for inclusion. Among preoperative variables, a pooled higher ratio of ASA > 2 patients was found in the robotic group (12.4 vs 8.6%, p < 0.001). Unilateral hernia repair was more common in the laparoscopic group (79.9 vs 68.1, p < 0.001). Overall, operative time was longer in the robotic group (160 vs 90 min, p < 0.001); this was confirmed also in the sub-analysis on unilateral procedures (88 vs 68 min, p = 0.040). The operative time for robotic bilateral repair was similar to the laparoscopic one (111 vs 100, p = 0.797). Conversion to open surgery was 0% in the robotic group. The pooled rate of chronic pain and postoperative complications was similar between the groups. The standardized mean difference MD of the costs between LHR versus RHR was − 3270$ (95% CI – 4757 to − 1782, p < 0.001). In conclusion, laparoscopic and robotic inguinal hernia repair have similar safety parameters and postoperative outcomes. Robotic approach may require longer operative time if the unilateral repair is performed. Costs are higher in the robotic group.

Trends and outcomes of open, laparoscopic, and robotic inguinal hernia repair in the veterans affairs system

PURPOSE

Robotic inguinal hernia repair (RHR) is an evolving technique but is comparatively expensive and has yet to show superior outcomes versus open (OHR) or laparoscopic (LHR) approaches. The utilization and clinical outcomes of RHR have not been reported within the veterans affairs (VA) system. This study analyzes trends in utilization and 30-day post-operative outcomes between OHR, LHR, and RHR in veterans.

METHODS

This is a retrospective review of patients that underwent inguinal herniorrhaphy using the Veterans Affairs Quality Improvement Program database. Multivariable analysis of outcomes was performed adjusting for pre-operative confounding covariates between OHR, LHR, and RHR. Trends in utilization, complication rates, and operative times were also reported.

RESULTS

From 2008-2019, 124,978 cases of inguinal herniorrhaphy were identified: 100,880 (80.7%) OHR, 18,035 (14.4%) LHR, and 6063 (4.9%) RHR. Compared to LHR, RHR was associated with 4.94 times higher odds of complications, 100 min longer mean operative time, and 1.5 days longer median length of stay (LOS). Compared to OHR, RHR was associated with 5.92 times higher odds of complications, 57 min longer mean operative time, and 1.1 days longer median LOS. Utilization of RHR and LHR significantly increased over time. RHR complication rates decreased over time (2008: 20.8% to 2019: 3.2%) along with mean operative times (2008: 4.9 h to 2019: 2.8 h; p < 0.05).

CONCLUSION

While this study demonstrated inferior outcomes after RHR, the temporal trends are encouraging. This may be due to increased surgeon experience with robotics. Further prospective data will elucidate the role of RHR as this technique increases.

Robotic Inguinal Hernia Repair Outcomes: Operative Time and Cost Analysis

Background

Robotic inguinal hernia repair is the latest iteration of minimally invasive herniorrhaphy. Previous studies have shown expedited learning curves compared to traditional laparoscopy, which may be offset by higher cost and longer operative time. We sought to compare operative time and direct cost across the evolving surgical practice of 10 surgeons in our healthcare system.

Methods

This is a retrospective review of all transabdominal preperitoneal robotic inguinal hernia repairs performed by 10 general surgeons from July 2015 to September 2018. Patients requiring conversion to an open procedure or undergoing simultaneous procedures were excluded. The data was divided to compare each surgeon's initial 20 cases to their subsequent cases. Direct operative cost was calculated based on the sum of supplies used intra-operatively. Multivariate analysis, using a generalized estimating equation, was adjusted for laterality and resident involvement to evaluate outcomes.

Results

Robotic inguinal hernia repairs were divided into two groups: early experience (n = 167) and late experience (n = 262). The late experience had a shorter mean operative time by 17.6 min (confidence interval: 4.06 - 31.13, p = 0.011), a lower mean direct operative cost by $538.17 (confidence interval: 307.14 - 769.20, p < 0.0001), and fewer postoperative complications (p = 0.030) on multivariate analysis. Thirty-day readmission rates were similar between both groups.

Conclusion

Increasing surgeon experience with robotic inguinal hernia repair is associated with a predictable reduction in operative time, complication rates, and direct operative cost per case. Thirty-day readmission rates are not affected by the learning curve.

Robotic inguinal hernia repair: systematic review and meta-analysis

BACKGROUND

We aimed to conduct a systematic review and meta-analysis of RHR's efficiency and safety, in addition to comparison between open and laparoscopic techniques.

METHODS

A literature review was conducted from 2000 to 2020 including studies reporting on their centre's outcomes for robotic hernial repairs. A meta-analysis was conducted. For continuous data, Mantel-Haenszel chi-squares test was used and inverse variance was used for dichotomous data.

RESULTS

In total, 19 studies were included. A total of 8987 patients were treated for hernia repairs, 4248 underwent open repairs, 2521 had robotic repairs and 1495 had laparoscopic repair. Cumulative analysis of robotic series: The overall average operative time was 90.8 min (range 25-180.7 min). The overall conversation rate was 0.63% (10/1596). The overall complication rate was 10.1% (248/2466). The overall recurrence rate was 1.2% (14/1218). Readmission rate was 1.6% (28/1750). Comparative meta-analysis outcomes include robotic versus open and robotic versus laparoscopic. Robotic versus open: The robotic group had significantly longer operative times and less readmission rates. There was no difference between the two groups regarding complications, post-operative pain occurrence and hernia recurrence rates. Robotic versus laparoscopic: The robotic group had significantly longer operative times and less complications. There was no difference regarding post-operative pain occurrence, hernia recurrence rates or readmission rates.

CONCLUSION

Robotic hernia repair is a safe and efficient technique with minimal complications and a short learning curve; however, it remains inferior to the standard open technique. It does, however, have a role in minimally invasive technique centres. A multicentre randomized control trial is required comparing robotic, open and laparoscopic techniques.

Economic assessment of starting robot-assisted laparoscopic inguinal hernia repair in a single-centre retrospective comparative study: the EASTER study

Background

There has been a rapid adoption of robot-assisted laparoscopic inguinal hernia repair in the USA, despite a lack of proven clinical advantage and higher material cost. No studies have been published regarding the cost and outcome of robotic inguinal hernia surgery in a European Union setting.

Methods

A retrospective comparative study was performed on the early outcome and costs related to laparoscopic inguinal hernia repair, with either conventional or robot-assisted surgery.

Results

The study analysed 676 patients undergoing laparoscopic inguinal hernia repair (272 conventional and 404 robotic repairs). Conventional laparoscopic and robotic repair groups were comparable in terms of duration of surgery (57.6 versus 56.2 min respectively; P = 0.224), intraoperative complication rate (1.1 versus 1.2 per cent; P = 0.990), in-hospital complication rate (4.4 versus 4.5 per cent; P = 0.230) and readmission rate (3.3 versus 1.2 per cent; P = 0.095). There was a significant difference in hospital stay in favour of the robotic approach (P = 0.014), with more patients treated on an outpatient basis in the robotic group (59.2 per cent versus 70.0 per cent for conventional repair). At 4-week follow-up, equal numbers of seromas or haematomas were recorded in the conventional laparoscopic and robotic groups (13.3 versus 15.7 per cent respectively; P = 0.431), but significantly more umbilical wound infections were seen in the conventional group (3.0 per cent versus 0 per cent in the robotic group; P = 0.001). Robotic inguinal hernia repair was significantly more expensive overall, with a mean cost of €2612 versus €1963 for the conventional laparoscopic approach (mean difference €649; P < 0.001).

Conclusion

Robot-assisted laparoscopic inguinal hernia repair was significantly more expensive than conventional laparoscopy. More patients were treated as outpatients in the robotic group. Postoperative complications were infrequent and mild.

Comparative perioperative and 5-year outcomes of robotic and laparoscopic or open inguinal hernia repair: a study of 153,727 patients in the state of New York

OBJECTIVE

This study aimed to examine the perioperative outcomes of robotic inguinal hernia repair as compared to the open and laparoscopic approaches utilizing large-scale population-level data.

METHODS

This study was funded by the SAGES Robotic Surgery Research Grant (2019). The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify all adult patients undergoing initial open (O-IHR), laparoscopic (L-IHR), and robotic (R-IHR) inguinal hernia repair between 2010 and 2016. Perioperative outcome measures [complications, length of stay (LOS), 30-day emergency department (ED) visits, 30-day readmissions] and estimated 1/3/5-year recurrence incidences were compared. Propensity score (PS) analysis was used to estimate marginal differences between R-IHR and L-IHR or O-IHR, using a 1:1 matching algorithm.

RESULTS

During the study period, a total of 153,727 patients underwent inguinal hernia repair (117,603 [76.5%] O-IHR, 35,565 [23.1%] L-IHR; 559 [0.36%] R-IHR) in New York state. Initial univariate analysis found R-IHR to have longer LOS (1.74 days vs. 0.66 O-IHR vs 0.19 L-IHR) and higher rates of overall complications (9.3% vs. 3.6% O-IHR vs 1.1% L-IHR), 30-day ED visits (11.6% vs. 6.1% O-IHR vs. 4.9% L-IHR), and 30-day readmissions (5.6% vs. 2.4% O-IHR vs. 1.2% L-IHR) (p < 0.0001). R-IHR was associated with higher recurrence compared to L-IHR. Following PS analysis, there were no differences in perioperative outcomes between R-IHR and L-IHR, and the difference in recurrence was found to be sensitive to possible unobserved confounding factors. R-IHR had significantly lower risk of complications (Risk difference - 0.09, 95% CI [- 0.13, - 0.056]; p < 0.0001) and shorter LOS (Ratio 0.53, 95% CI [0.45, 0.62]; p < 0.0001) compared to O-IHR.

CONCLUSION

In adult patients, R-IHR may be associated with comparable to more favorable 30-day perioperative outcomes as compared with L-IHR and O-IHR, respectively.

Learning curve of robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias

BACKGROUND

Learning curves describe the rate of performance improvements according to the surgeon's caseload, followed by a plateau where limited additional improvements are observed. The aim of this study was to evaluate the learning curve for robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias in surgeons already experienced in laparoscopic TAPP.

METHODS

The study was approved by local ethic committee. Male patients undergoing rTAPP for inguinal hernia from October 2017 to December 2019 at the Bellinzona Regional Hospital were selected from a prospective database. Demographic and clinical data, including operative time, conversion to laparoscopic or open surgery, intra- and postoperative complications were collected and analyzed.

RESULTS

Over the study period, 170 rTAPP were performed by three surgeons in 132 patients, and mean age was 60.1 ± 13.7 years. The cumulative summation (CUSUM) test showed a significant operative time reduction after the 43^rd operation, once the 90% proficiency on the logarithmic tendency line was achieved. The corrected operative time resulted 71.1 ± 22.0 vs. 60.8 ± 13.5 min during and after the learning curve (p = 0.011). Only one intraoperative complication occurred during the learning curve and required an orchiectomy. Postoperatively, three complications (one seroma, one hematoma, and one mesh infection) required invasive interventions during the learning curve, while no cases were recorded after it (p = 0.312).

CONCLUSION

Our study shows that the rTAPP, performed by experienced laparoscopists, has a learning curve which requires 43 inguinal hernia repairs to achieve 90% proficiency and to significantly reduce the operative time.

Safety and efficacy of robotic-assisted groin hernia repair

Robotic surgical technology has grown in popularity and applicability, since its conception with emerging uses in general surgery. The robot's contribution of increased stability and dexterity may be beneficial in technically challenging surgeries, namely, inguinal hernia repair. The aim of this project is to contribute to the growing body of literature on robotic technology for inguinal hernia repair (RIHR) by sharing our experience with RIHR at a large, academic institution. We performed a retrospective chart review spanning from March 2015 to April 2018 on all patients who had undergone RIHR at our university hospital. Extracted data include preoperative demographics, operative features, and postoperative outcomes. Data were analyzed with particular focus on complications, including hernia recurrence. A total of 43 patients were included, 40 of which were male. Mean patient age was 56 (range 18-85 years) and mean patient BMI was 26.4 (range 17.5-42.3). Bilateral hernias were diagnosed in 13 patients. All of the patients received transabdominal approaches, and all but one received placement of synthetic polypropylene mesh. There was variety in mesh placement with 23 patients receiving suture fixation and 14 receiving tack fixation. Several patients received a combination of suture, tacks, and surgical glue. Mean patient in-room time was 4.0 h, mean operative time was 2.9 h, and mean robotic dock time was 2.0 h. Regarding intraoperative complications, there was one bladder injury, which was discovered intraoperatively and repaired primarily. Same-day discharges were achieved in 32 patients (74.4%) of patients. One patient was admitted overnight for management of urinary retention. Additional ten patients were admitted for observation. Post-operatively, none of the cases resulted in wound infections. Eleven patients developed seromas and one patient was diagnosed with a groin hematoma. Median follow-up was 37.5 days, and one recurrence was reported during this time. The recurrent hernia in this case was initially discovered during a separate case and was repaired with temporary mesh. The use of the robot is safe and effective and should be considered an acceptable approach to inguinal hernia repair. Future prospective studies will help define which patients will benefit most from this technology.

Robotic-assisted single site (RASS) TAPP: an advantageous choice? : Outcomes of single site robotic groin hernia repair

PURPOSE

Laparoscopic transabdominal preperitoneal (TAPP) is a valid option for bilateral primary groin hernia and recurrent cases. Robotic approach for inguinal hernia is still debated. The aim of this study is to investigate the potential role of robotic-assisted single site-TAPP (RASS-TAPP) reporting our experience.

METHODS

We performed 44 RASS TAPP in 32 patients from February 2016 to July 2018. Data on patient demographics, type of hernia, operative time, complications, recurrence rate and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1 week, 4 months and 1 year after surgery.

RESULTS

Forty-two hernias were treated in 32 patients (27 M). Mean age was 48.6 years (range 20-67), mean BMI was 26.49 kg/m² (range 16-34.9). Mean operative time was 54.8 min (range 28-150). In two cases (6%) a conversion to laparoscopy was necessary. At 1 week, two scrotal hematomas and four seromas were observed and treated conservatively. At 4 months follow-up, one patient (3.1%) complained temporary pain. No patient had inguinal recurrence or incisional umbilical hernia and chronic pain at 1-year follow-up.

CONCLUSION

RASS TAPP is feasible and safe with a high patient satisfaction. However, the surgeon experiences a technical discomfort due to the conflict of the instrumentation which influences negatively the choice of this approach, despite the better vision and augmented dexterity provided by the robot.

Evolution of the Surgical Residency System in Switzerland: An In-Depth Analysis Over 15 Years

BACKGROUND

The landscape of surgical training has been subject to many changes over the past 15 years. This study examines resident satisfaction, determinants of satisfaction, demographics, working hours and the teaching rate of common operations in a longitudinal fashion with the aim to identify trends, shortcomings and possible ways to improve the current training system.

METHODS

The Swiss Medical Association administers an annual survey to all Swiss residents to evaluate the quality of postgraduate medical training (yearly respondents: 687-825, response rate: 68-72%). Teaching rates for general surgical procedures were obtained from the Swiss association for quality management in surgery.

RESULTS

During the study period (2003-2018), the number of surgical residents (408-655 (+61%)) and graduates in general surgery per year (42-63 (+50%)) increased disproportionately to the Swiss population. While the 52 working hour restriction was introduced in 2005 reported average weekly working hours did not decline (59.9-58.4 h (-3%)). Workplace satisfaction (6 being highest) rose from 4.3 to 4.6 (+7%). Working climate and leadership culture were the main determinants for resident satisfaction. The proportion of taught basic surgical procedures fell from 24.6 to 18.9% (-23%).

CONCLUSIONS

The number of residents and graduates in general surgery has risen markedly. At the same time, the proportion of taught operations is diminishing. Despite the introduction of working hour restrictions, the self-reported hours never reached the limit. The low teaching rate combined with the increasing resident number represents a major challenge to the maintenance of the current training quality.

Novel robot-assisted laparoscopic total extra-peritoneal repair with primary fascial closure plus pre-peritonea mesh for large groin defects

BACKGROUND

Since the introduction of robot-assisted laparoscopic surgery, a variety of conventional laparoscopic procedures have been explored via this approach. In the robotic era, most of the reported robot-assisted laparoscopic hernia repairs were performed with the trans-abdominal pre-peritoneal approach. According to the evidence extrapolated from laparoscopic ventral hernia repair, simultaneous fascial defect closure and mesh repair can significantly decrease the risk of seroma formation and recurrence over those without fascial closure. Therefore, we describe our novel technique of robot-assisted total extra-peritoneal (TEP) repair with primary fascial closure and pre-peritoneal mesh and its preliminary clinical outcomes.

METHODS

We retrospectively reviewed our prospectively collected hernia database from October 2017 to July 2019, which included 26 consecutive patients with primary or recurrent groin hernias. Patients' baseline characteristics and perioperative outcomes were compared and analyzed. Perioperative factors included operative time, visual analog scale (VAS) score (0-100), hospital stay, perioperative complications, time to return to normal activity, and the modified Medical Outcome Study (MOS; item 3-12/36 items) score.

RESULTS

All procedures were completed successfully without conversion to open or conventional laparoscopic surgery. The patients' age ranged from 28 to 74 years (median 57.5). The mean operative time was 115 minutes (range 95-172 min). There were no major procedure-related complications. Only four cases experienced asymptomatic seromas, which were detected by ultrasonography; and all resolved spontaneously within 6 weeks after the operation. The VAS and modified MOSs revealed quick recovery after robot-assisted endoscopic TEP repair.

CONCLUSIONS

Robot-assisted endoscopic TEP repair combined with primary fascial closure and pre-peritoneal mesh is a safe and feasible technique for groin hernia repair.

Perioperative outcomes and cost of robotic-assisted versus laparoscopic inguinal hernia repair

BACKGROUND

Utilization of robotic-assisted inguinal hernia repair (IHR) has increased in recent years, but randomized or prospective studies comparing outcomes and cost of laparoscopic and Robotic-IHR are still lacking. With conflicting results from only five retrospective series available in the literature comparing the two approaches, the question remains whether current robotic technology provides any added benefits to treat inguinal hernias. We aimed to compare perioperative outcomes and costs of Robotic-IHR versus laparoscopic totally extraperitoneal IHR (Laparoscopic-IHR).

METHODS

Retrospective analysis of consecutive patients who underwent Robotic-IHR or Laparoscopic-IHR at a dedicated MIS unit in the USA from February 2015 to June 2017. Demographics, anthropometrics, the proportion of bilateral and recurrent hernias, operative details, cost, length of stay, 30-day readmissions and reoperations, and rates and severity of complications were compared.

RESULTS

183 patients had surgery: 45 (24.6%) Robotic-IHR and 138 (75.4%) Laparoscopic-IHR. There were no differences between groups in age, gender, BMI, ASA class, the proportion of bilateral hernias and recurrent hernias, and length of stay. Operative time (Robotic-IHR: 116 ± 36 min, vs. Laparoscopic-IHR: 95±44 min, p < 0.01), reoperations (Robotic-IHR: 6.7%, vs. Laparoscopic-IHR: 0%, p = 0.01), and readmissions rates were greater for Robotic-IHR. While the overall perioperative complication rate was similar in between groups (Robotic-IHR: 28.9% vs. Laparoscopic-IHR: 18.1%, p = 0.14), Robotic-IHR was associated with a significantly greater proportion of grades III and IV complications (Robotic-IHR: 6.7% vs. Laparoscopic-IHR: 0%, p = 0.01). Total hospital cost was significantly higher for the Robotic-IHRs ($9993 vs. $5994, p < 0.01). The added cost associated with the robotic device itself was $3106 per case and the total cost of disposable supplies was comparable between the 2 groups.

CONCLUSIONS

In the setting in which it was studied, the outcomes of Laparoscopic-IHR were significantly superior to the Robotic-IHR, at lower hospital costs. Laparoscopic-IHR remains the preferred minimally invasive surgical approach to treat inguinal hernias.

The paradox of the robotic approach to inguinal hernia repair in the inpatient setting

BACKGROUND

Robotics offers improved ergonomics, enhanced visualization, and increased dexterity. Disadvantages include startup, maintenance and instrument costs. Surgeon education notwithstanding, we hypothesized that robotic inguinal hernia repair carries minimal advantages over the open or laparoscopic approach in the inpatient setting.

METHODS

The HCUP-SID and AHA datasets were queried for inguinal hernia repair codes. Hospital and patient demographic, financial and comorbidity data were evaluated. Data are presented as mean ± SEM.

RESULTS

36396 cases (27776 Open, 7104 Laparoscopic and 1516 Robotic) were identified. Total costs were: $13595 ± 104 (Open), $13581 ± 176 (Laparoscopic) and $18494 ± 323 (Robotic). (p < 0.0001 Robotic vs Open, Robotic vs Laparoscopic) Robotic costs were 38% greater than that of the Open and Laparoscopic subsets (p < 0.001 Robotic vs. Open and Laparoscopic). The Open, Laparoscopic and Robotic subsets' length of stay were 4.2, 3.2 and 2.3 days, respectively. (p < 0.0001 among Open, Laparoscopic and Robotic).

CONCLUSION

The Robotic approach to the inguinal hernia repair had the lowest length of stay, despite having the highest costs. The benefits of robotic surgery in inguinal hernia repair are unclear in the inpatient setting.

Robotic inguinal hernia repair: is technology taking over? Systematic review and meta-analysis

PURPOSE

To examine the current evidence on the therapeutic role and outcomes of robotic Transabdominal Preperitoneal Inguinal hernia repair (rTAPP) to better define its risk-benefit ratio and guide clinical decision-making.

METHODS

PubMed, EMBASE, and Web of Science were consulted. A Frequentist single-arm study-level random effect meta-analysis was performed.

RESULTS

Twelve studies published between 2015 and 2018 met the inclusion criteria (1645 patients). Patients' age ranged from 16 to 96, the BMI ranged from 19 to 35.6 kg/m², and 86.1% were males. Unilateral hernia repair was performed in 69.6% while bilateral hernia repair was performed in 30.4% of patients. The operations were all conducted using the da Vinci Xi or Si robotic system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). The rTAPP was successfully completed in 99.4% of patients and the operative time ranged from 45 to 180.4 min. The postoperative follow-up ranged from 16 to 368 days. The estimated pooled prevalence of intraoperative complications and conversion were 0.03% (95% CI 0.00-0.3) and 0.14% (95% CI 0.0-0.5%), respectively. The estimated pooled prevalence of urinary retention, seroma/hematoma, and overall complications were 3.5% (95% CI 1.6-5.8%), 4.1% (95% CI 1.6-7.5%), and 7.4% (95% CI 3.4-10.9%). The estimated pooled prevalence of hernia recurrence was 0.18% (95% CI 0.00-0.84%).

CONCLUSIONS

Robotic technology has been progressively entering surgical thinking and gradually changing surgical procedures. Based on the results of the present study, the rTAPP seems feasible, safe, and effective in the short term for patients with unilateral and bilateral inguinal hernias. Further prospective studies and randomized controlled trials are needed to validate these findings.

Primary inguinal hernia: systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair

PURPOSE

The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair.

METHODS

PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed.

RESULTS

Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50-1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32-1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39-1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37-2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27-1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48-1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63-3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57-1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65-1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63-2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45-2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay.

CONCLUSIONS

This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.

Minimally invasive inguinal hernia repair is superior to open: a national database review

PURPOSE

Many publications have focused on single-surgeon or single-center data, comparing surgical approach in inguinal hernia repair. This study evaluated outcomes in patients who underwent open (OIHR), laparoscopic (LIHR) or robotic (RIHR) inguinal hernia repair using a national database.

METHODS

The Vizient clinical database was queried using ICD-9 and ICD-10 procedure and diagnosis codes for RIHR, LIHR, and OIHR from 2013 to 2017. Elective procedures classified as minor or moderate risk severity were included. Complications, 30-day readmission, mortality, LOS, and intra-hospital opiate utilization were analyzed using IBM SPSS v.23.0.

RESULTS

3547 patients (OIHR: N = 2413, LIHR: N = 540, RIHR: N = 594) were included in the study. Majority were male (OIHR 84.1%, LIHR 80.4%, RIHR 95.3%), ≥ 51 years (OIHR 81.5%, LIHR 81.7%, RIHR 95.3%), and Caucasian (OIHR 75.7%, LIHR 77.0%, RIHR 81.5%). RIHR had the least overall complications (0.67%) compared to LIHR (4.44%) and OIHR (3.85%), p < 0.05. OIHR had the highest postoperative infection rate (8.33%), versus LIHR (0.56%) and RIHR (0.0%), p < 0.05. OIHR had longer length of stay (3.57 ± 4.1 days) when compared to both groups (LIHR 2.2 ± 2.13 days, RIHR 1.75 ± 1.62 days), p < 0.001. OIHR had higher 30-day readmission rates (3.61%) compared to RIHR (0.84%), p = 0.001. Mortality was similar between groups (OIHR 0.21%, LIHR 0.19%, RIHR 0.17%), p = 0.081. Opiate use was higher with OIHR (96.0%), compared to both LIHR (93.1%), and RIHR (93.8%), p = 0.004.

CONCLUSION

RIHR outcomes were improved compared to OIHR or LIHR. OIHR had the highest rate of opiate use, there was no difference between LIHR and RIHR. Further studies are needed to determine the role of RIHR and to assess whether surgeon or patient selection contributes to outcomes.

Predictors of Robotic Versus Laparoscopic Inguinal Hernia Repair

BACKGROUND

The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR).

METHODS

We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression.

RESULTS

The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05).

CONCLUSIONS

The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.

Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Outcomes and Predictors of Complications

BACKGROUND

The robotic approach to an inguinal hernia has not been compared head to head with the open and laparoscopic techniques in randomized controlled trials. Furthermore, long-term outcomes for robotic inguinal hernia repair (RHR) are lacking. In this study, we compared laparoscopic inguinal hernia repair (LHR) and RHR with open inguinal hernia repair (OHR) in veteran patients performed by surgeons most familiar with each approach.

METHODS

A retrospective single-institution analysis of 1299 inguinal hernia repairs performed at the VA North Texas Health Care System between 2005 and 2017 was undertaken. Three surgeons performed the operations, each an expert in one approach, and there was no crossover in techniques. A total of 1100 OHRs, 128 LHRs, and 71 RHRs were performed. Univariable analysis was undertaken to determine associations between techniques and outcomes (OHR versus LHR; OHR versus RHR; LHR versus RHR). Setting complications as a dependent variable, multivariable analyses were undertaken to determine an association with complications as well as independent predictors of complications.

RESULTS

Patient demographics were similar among groups except for age that was higher in the OHR cohort. The average follow-up was 5.2 ± 3.4 y. In the present report, recurrence was associated with a higher rate in the RHR versus OHR (5.6% versus 1.7%; P < 0.02), but not in the LHR versus OHR (3.9% versus 1.9%; P = 0.09). Inguinodynia was more likely to occur in both the LHR and RHR compared with the OHR (9.4% and 14.1 versus 1.5%; both P's < 0.001). Urinary retention was also more common in the LHR and RHR than in the OHR (5.5% and 5.6% versus 1.8%, both P's < 0.05) as was the rate of overall complications (34.4% and 38.0% versus 11.2%, both P's < 0.001). Multivariable regression analysis showed femoral hernias, ASA, serum albumin, operative room time, a recurrent hernia, and the minimally invasive approaches were independent predictors of overall complications.

CONCLUSIONS

Outcomes in the OHR cohort were, in general, superior compared with both the LHR and RHR. However, these strategies should be viewed as complementary. The best approach to an inguinal hernia repair rests on the specific expertise of the surgeon.

Current status of single-port versus multi-port approach in laparoscopic inguinal hernia mesh repair: an up-to-date systematic review and meta-analysis

A meta-analysis was conducted to provide an up-to-date comparison of single-port and multi-port approach, in laparoscopic inguinal hernia mesh repair. This meta-analysis was performed on the basis of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic databases (MEDLINE, Web of Science and Cochrane Central Register of Controlled Clinical Trials) were systematically screened. Fixed Effects or Random Effects model was used, according to the Cochran Q test. In total 16 eligible studies were found. There was no statistically significant difference, regarding unilateral operation duration, between the two approaches, in TEP (OR - 4.61; 95% CI - 9.70, 0.47, p = 0.08) or TAPP (OR - 1.96; 95% CI - 4.89, 0.97, p = 0.19) procedures. Similarly, in both operative modalities, no superiority of either approach was proven, in terms of conversion rate (TEP OR 0.69, p = 0.48; TAPP OR 5.46, p = 0.31), length of hospital stay (TEP WMD 0.00, p = 0.76; TAPP WMD - 0.11, p = 0.42) and overall complication rate (TEP OR 1.10, p = 0.51; TAPP OR 0.74, p = 0.43). Overall, single-port and the established multi-port approach in inguinal hernia mesh repair, are equivalent, regarding the postoperative outcomes. Given several limitations, further RCTs, of higher methodological and quality level are required.

Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis

BACKGROUND

Cost-effectiveness of robotic-assisted surgery is still debatable. Robotic-assisted inguinal hernia repair has no clear clinical benefit over laparoscopic repair. We performed a comprehensive cost-analysis comparison between the two approaches for evaluation of their cost-effectiveness in a large healthcare system in the Western United States.

METHODS

Health records in 32 hospitals were queried for procedural costs of inguinal hernia repairs between January 2015 and March 2017. Elective robotic-assisted or laparoscopic unilateral inguinal hernia repairs were included. Cost calculations were done using a utilization-based costing model. Total cost included: fixed cost, which comprises medical device and personnel costs, and variable cost, which comprises disposables and reusable instruments costs. Other outcome measures were length of stay (LOS), conversion to open, and operative times. Statistics were done using t test for continuous variables and χ² test for categorical variables. A p-value < 0.05 was considered significant.

RESULTS

A total of 2405 cases, 734 robotic-assisted (633 Primary: 101 recurrent) and 1671 laparoscopic (1471 Primary: 200 recurrent), were included. The average total cost was significantly higher (p < 0.001) in the robotic-assisted group ($5517) compared to the laparoscopic group ($3269). However, the average laparoscopic variable cost ($1105) was significantly higher (p < 0.001) than the robotic-assisted cost ($933). Whereas there was no significant difference between the two groups for LOS and conversion to open, average operative times were significantly higher in the robotic-assisted group (p < 0.001). Subgroup analysis for primary and recurrent inguinal hernias matched the overall results.

CONCLUSIONS

Robotic-assisted inguinal hernia repair has a significantly higher cost and significantly longer operative times, compared to the laparoscopic approach. The study has shown that only fixed cost contributes to the cost difference between the two approaches. Medical device cost plus the longer operative times are the main factors driving the cost difference. Laparoscopic unilateral inguinal hernia repair is more cost-effective compared to a robotic-assisted approach.

INGUINAL REPAIR VIA ROBOTIC ASSISTED TECHNIQUE: LITERATURE REVIEW

Introduction:

Inguinal hernia is one of the most frequent surgical diseases. Currently, with the advantages of minimally invasive surgery, new questions arise: what will be the best approach for correction of inguinal hernia? Is there real benefit to the robotic approach?

Objective:

To compile results of the published studies that used the robot-assisted technique in the repair of inguinal hernia, analyzing its limitations, complications and comparing it with those of the pre-existing techniques.

Method:

The review was performed from the Medline database with the following descriptors: (inguinal hernia repair OR hernioplasty OR hernia) AND (robot OR robotic OR robotic assisted) being retrieved 391 articles. After verification of the titles and abstracts, we identified eight series of cases congruent with the objectives of this review. Three reviewers participated in the extraction and selection of results.

Results:

Comparative studies showed an increase in surgical time in relation to the open and videolaparoscopic approach. The complications present similar rates with the other repair routes.

Conclusion:

This technique has been shown to be effective for the correction of inguinal hernia, but the benefits of using robotic surgery are unclear. So, there is a need for randomized studies comparing laparoscopic to robotic repair

Robot-assisted abdominal wall surgery: a systematic review of the literature and meta-analysis

PURPOSE

The number of robot-assisted hernia repairs is increasing, but the potential benefits have not been well described. The aim of this study was to evaluate the available literature reporting on outcomes after robot-assisted hernia repairs.

METHODS

This is a qualitative review and meta-analysis of papers evaluating short-term outcomes after inguinal or ventral robot-assisted hernia repair compared with either open or laparoscopic approach. The primary outcome was postoperative complications and secondary outcomes were duration of surgery, postoperative length of stay and financial costs.

RESULTS

Fifteen studies were included. Postoperative complications were significantly decreased after robot-assisted inguinal hernia repair compared with open repair. There were no differences in complications between robot-assisted and laparoscopic inguinal hernia repair. For ventral hernia repair, sutured closure of the defect, retromuscular mesh placement and transversus abdominis release is feasible when using the robot. Length of stay was decreased by a mean of 3 days for robot-assisted repairs compared with open approach. There were no differences in postoperative complications and the operative time was significantly longer for robot-assisted ventral hernia repair compared with laparoscopic or open approach.

CONCLUSIONS

For ventral hernias that would normally require an open procedure, a robot-assisted repair may be a good option, as the use of a minimally invasive approach for these procedures decreases length of stay significantly. For inguinal hernias, the benefit of the robot is questionable. Randomized controlled trials and prospective studies are needed.

Robotic Inguinal Hernia Repair: A Large Health System's Experience With the First 300 Cases and Review of the Literature

BACKGROUND

Over the past 5 y, robotic surgery has expanded within general surgery, especially in regard to hernia repairs. We aimed to evaluate the outcomes of the early experience of over 300 consecutive robotic inguinal hernia repairs performed in an academic multihospital system.

METHODS

Consecutive robotic inguinal hernia repairs performed between December 2015 and June 2017 were analyzed. Retrospective chart review was performed, and hospital records were queried. Descriptive statistics were performed. A surgical learning curve case study is presented, breakdown of operative time is delineated, and review of the literature performed.

RESULTS

Over a period of 19 mo, 335 robotic inguinal hernia repairs were performed across seven hospitals by 18 surgeons. The mean patient age was 59 y (standard deviation [SD] 14), 93% were male, and the mean body mass index was 27 (SD 4.6). Bilateral hernia repairs were performed on 131 patients (39%). The mean operative time was 102 min (SD 38) and a resident or fellow trainee was present in the operating room for 119 cases (36%). Minor postoperative complications occurred in 54 patients (16%), including 14 with urinary retention (4.2%) and 13 with scrotal swelling (3.9%). The learning curve of the first adopted surgeon was 11-12 cases.

CONCLUSIONS

In the largest case series of robotic inguinal hernia repairs to date reporting short-term outcomes, early experience in an academic multihospital system produced safe outcomes including no open conversions, reoperations, and one readmission. In addition, the learning curve is manageable showing improvement in operating time with experience.

Robotic-assisted Laparoscopic Repair of Scrotal Inguinal Hernias

BACKGROUND

Scrotal inguinal hernias represent a challenging surgical pathology. Although some advanced laparoscopists can repair these hernias through a minimally invasive approach, open repair is considered the technique of choice for most surgeons. The purpose of this study is to show our results of robotic-assisted laparoscopic repair of scrotal inguinal hernias.

PATIENTS AND METHODS

We reviewed the charts of 14 patients with inguinoscrotal hernias who underwent robotic-assisted transabdominal preperitoneal (TAPP) hernia repair. Mean follow-up was 7 months. The European Registry for Abdominal Wall Hernia Quality of Life score, a 90-point scale, was utilized to quantify patient reported outcomes.

RESULTS

Robotic TAPP repair was successful in all 14 patients. Average case duration was 100 minutes (78 to 140 min) for unilateral hernias and 208 minutes (166 to 238 min) for bilateral hernias. Trainees were involved in 93% (13/14) of cases. There were no recurrences. Three patients developed postoperative seromas. The mean European Registry for Abdominal Wall Hernia Quality of Life score was 3.7 (0 to 10).

CONCLUSIONS

Scrotal hernias can be safely repaired using robotic-assisted TAPP methods with low morbidity and favorable patient reported outcomes.

Robotic-assisted laparoscopic groin hernia repair: observational case-control study on the operative time during the learning curve

BACKGROUND

Robotic groin hernia repair (r-TAPP) is demonstrating rapid adoption in the US. Barriers in Europe include: low availability of robotic systems to general surgeons, cost of robotic instruments, and the perception of longer operative time.

METHODS

Patients undergoing r-TAPP in our start-up period were prospectively entered in the EuraHS database and compared to laparoscopic TAPP (l-TAPP) performed by the same surgeon within the context of two other prospective studies. Operations were performed with the daVinci Xi robot and the primary endpoint was skin-to-skin operative time.

RESULTS

Following proctoring in September 2016 by US surgeons, 50 r-TAPP (34 unilateral and 16 bilateral) procedures have been performed up to January 2017. Mean operative time for unilateral r-TAPP was 54 min, with a decrease from 63 min for the first tertile to 44 min for the third tertile. For unilateral l-TAPP, the mean operative time was 45 min. Mean operative time for bilateral r-TAPP was 78 min, with a decrease from 90 min for the first half to 68 min for the second half. For bilateral l-TAPP, the mean operative time was 61 min. There were no intraoperative complications and no conversions to conventional laparoscopy or open surgery. The operation was performed as an outpatient in 67% of cases. Urinary retention requiring urinary catheterization was the only early postoperative complication noted in 5 patients (10.2%). At 4 week follow-up, 7 patients (14.3%) had an asymptomatic seroma, but no other complications were seen.

CONCLUSION

Robotic TAPP was associated with a rapid reduction in operative time during our learning curve and afterwards the operative time to perform a robotic TAPP equals the operative time to perform a laparoscopic TAPP, both for unilateral and for bilateral groin hernia repairs. No complications related to the introduction of robotic-assisted laparoscopic groin hernia repair were observed.