The Role of Robotics in Hernia Repair
Perhaps no surgical technology generates as much fervent support or vehement criticism as the robot. While few would dispute the technical advantages of articulating instruments and 3D visualization, many have questioned the widespread adoption without clear evidence supporting its use, particularly in the face of significant initial cost. Adoption of robotic ventral and inguinal hernia repair (rVHR and rIHR) should be evaluated critically in four major areas:
This brief overview will examine the benefits, limitations and controversies surrounding robotics in hernia repair.
Clinical Outcomes in rIHR
Current literature on rIHR is limited, but indicates comparable risk for complications, recurrence and patient satisfaction to laparoscopic IHR (LIHR). There is a robust body of literature supporting LIHR, demonstrating reduced acute postoperative pain and incidence of chronic postoperative inguinal pain, and similar rates of complications and recurrence to traditional open repair (Hernia 2018;22:1-165). Robotic IHR emulates LIHR with some minor variations in technique, notably a transition to predominantly transabdominal preperitoneal (TAPP) repair from a predominantly totally extraperitoneal (TEP) approach for LIHR. Additionally, few surgeons performing rIHR use tack or staple fixation and use sutures to close the peritoneal flap, which may reduce postoperative pain.
Early results of a multicenter prospective trial of more than 500 patients comparing open IHR, LIHR and rIHR favor LIHR and rIHR over open IHR, with similar outcomes between the two. Fewer patients reported taking opioid analgesia in the rIHR group compared with LIHR, although the mean number of pills was no different (Hernia 2020;362:1561-1565). In the RIVAL trial, a prospective randomized multicenter trial of laparoscopic versus robotic TAPP IHR, no difference was seen in complications, readmissions, pain, physical activity or cosmesis (JAMA Surg 2020;155:380-387). The excellent clinical outcomes of LIHR will make it difficult to prove the superiority of rIHR, and these should be considered equivalent at this point.
Clinical Outcomes of rVHR
There are several variations of rVHR that must be considered.
Robotic Intraperitoneal Only of Mesh
Robotic IPOM is a modification of standard laparoscopic VHR, utilizing a transabdominal approach to bridge or reinforce the hernia with intraperitoneal mesh. This technique is the simplest and the most commonly performed rVHR, and has the distinct advantage of reliable closure of the hernia defect. Reinforcement of a closed defect rather than bridging has mechanical advantages, particularly for larger defects, that reduce the risk for mesh eventration and recurrence, and may decrease the rate of seroma (Hernia 2017;20:893-895; Surg Endosc 2019;33:3069-3139). Additionally, most surgeons performing rIPOM fixate the mesh with intracorporeal sutures rather than tacks or transfascial sutures. Advocates report less postoperative pain with this approach, although this has not been clearly demonstrated in the literature.
Robotic TAPP Repair
While relatively uncommon, complications of intraperitoneal mesh can be devastating. Further, intraperitoneal mesh may complicate subsequent abdominal operations, which are required in as many as 25% of patients after hernia repair (J Am Coll Surg 2011;212:496-502). This has led many to prefer extraperitoneal mesh placement. Robotic TAPP utilizes the preperitoneal space for mesh reinforcement, mitigating these risks associated with IPOM. Reports of rTAPP compare favorably to LVHR and rIPOM (Hernia 2020 May 5. Epub ahead of print]; Hernia 2019;23:957-967). There is little risk for damage to the abdominal wall with this procedure, and if the peritoneal flap integrity cannot be maintained, conversion to IPOM is straightforward.
Robotic Retromuscular Repair
Probably the most innovative application of rVHR is the reconstruction of the abdominal wall. Widely considered the gold standard for open repair, retromuscular (RM) VHR provides rectus abdominis myofascial release to allow defect closure and creates an extraperitoneal plane for mesh placement. The addition of a transversus abdominis release (TAR) further mobilizes the abdominal wall for closure of larger hernia defects and wider mesh reinforcement.
A transabdominal approach can be used to access the RM space, most often with the addition of TAR. This approach reduces the length of stay compared with open and laparoscopic IPOM, and may reduce surgical site infections (Ann Surg 2018;267:210-217; Surg Endosc 2017;31:324-332). However, its application should be limited to patients with larger defects that would require TAR, if performed open, to avoid unnecessary myofascial release.
Recently, the extended-view totally extraperitoneal (eTEP) repair has garnered significant attention, and is our preferred approach for most rVHR. This technique allows a more tailored approach by first releasing the rectus sheath alone, with additional rTAR only if needed. eTEP has allowed us to convert from traditional open RM VHR or LVHR with an inpatient stay of one to three days to an outpatient procedure in most cases, a finding reported by other authors as well (Hernia 2018;22:837-847; Surg Endosc 2020;23:957-1007).
Surgeon Advantages of rIHR
Proponents often cite ergonomic benefits of the robot. Musculoskeletal injury is a known hazard of laparoscopic surgery (J Am Coll Surg 2010;210:306-313). The ability to sit down and adjust the robotic console components is appealing. However, there remains a risk for injury. In the RIVAL trial, surgeon ergonomics were not significantly different between LIHR and rIHR, both demonstrating a high risk for musculoskeletal injury (JAMA Surg 2020;155:380-387). A study of ergonomics in robotic gynecologic surgery reported similar findings (J Minim Invasive Gynecol 2013;20:648 -655). Greater awareness and education are needed to mitigate this risk and take advantage of the potential ergonomic benefits of the robotic platform.
The learning curve of complex laparoscopy is significant, requiring up to 200 laparoscopic IHRs to reach proficiency, which contributes to its relatively limited adoption (Hernia 2018;22:1-165). The robot may shorten the learning curve of minimally invasive IHR (Surg Endosc 2018;32:4850-4859). Robotic simulation very closely approximates the reality of operating on the system. Additionally, through novel training and mentorship paradigms, most notably the International Hernia Collaboration (IHC) and Robotic Surgery Collaboration (RSC), there is a wealth of video-based technical instruction and almost real-time peer review available to new surgeons adopting rIHR or rVHR. It remains to be seen whether this will lead more surgeons to transition from open to minimally invasive IHR.
Cost of Robotic Hernia Repair
Disparate data exist on the costs associated with robotic compared with open or laparoscopic repairs (JAMA Surg 2020;155:380-387; J Robot Surg 2016;10:239-244). The initial expense of the robot and associated maintenance contracts are significant. Patient charges are likely higher after robotic repair (J Am Coll Surg 2020;231:61-72). However, these results are not necessarily generalizable. Direct hospital costs can vary depending on vendor contracts and individual surgeon supply utilization. Indirect costs vary according to billing structure and payor contracts. Potential cost savings of shorter length of stay should offset the cost for rVHR. Finally, quantifying the potential benefit of earlier return to work is challenging. At this point, robotic surgery cannot be judged solely on the basis of cost.
Residency or fellowship programs are the best model for training in novel surgical techniques, but this excludes practicing surgeons. For these surgeons, training is done primarily through industry-sponsored programs, postgraduate courses in conjunction with society meetings, live proctoring, self-guided learning, and virtual mentorship via groups such as the IHC or RSC. While this is adequate for many surgeons, it may not be for all, and there is no way to accurately assess proficiency of the learner. There are legitimate concerns from high-volume hernia referral centers, including our own, that some adopting these techniques may not appreciate the subtleties of the RM and TAR anatomy, resulting in disruption of the semilunar line and complex lateral hernias (Hernia 2020;24:333-340). It is imperative that we continue to explore innovative options for mentoring surgeons in novel techniques.
Interest in robotic hernia repair will undoubtedly continue, and adoption almost certainly will increase. While there will continue to be critics of robotic hernia repair, the ideal application of this innovative and enabling technology will become clearer as data emerge from ongoing clinical trials.
Dr. Warren is an associate professor of surgery at the University of South Carolina School of Medicine in Greenville.
Disclosure: Dr. Warren serves as an instructor and speaker for and receives honoraria from Intuitive.