Clinical and Cost Outcomes of Robot-Assisted Inguinal Hernia Repair: A Systematic Review

Abstract

Inguinal hernia repair is one of the most common general surgical procedures, with more than 20 million hernias repaired worldwide annually. 1 While most surgeons use an open approach, there has been a growth in laparoscopic and robotic techniques among unilateral, bilateral, and recurrent hernia repairs. 2,3 Advantages have been lauded, with laparoscopic and robotic repair allowing for superior visualization of bilateral groin anatomy and exploration of both inguinal and femoral spaces. Also, some reports suggest that patients may have less postoperative pain. 4 A recent study found that robotic inguinal hernia repair use increased 41-fold in Michigan (2012 to 2018). 5 Proponents of the robotic platform argue that its magnified 3-dimensional visualization, stable platform, and superior range of motion may translate into better clinical outcomes. 6 The number of robotic inguinal hernia repair procedures continues to rise despite confirmation of the clinical benefits. 7,8 The economic value of robotic surgery is also unclear. Technology acquisition and implementation require substantial upfront investment along with ongoing costs for annual maintenance contracts, instrument purchases, staff and training, infrastructure upgrades, and marketing. 9 The cost benefit in relationship to clinical outcomes associated with the use of robotic technology must be apparent to provider and patient.Two systematic reviews of robotic inguinal hernia repair were published in 2019 but are already dated, as at least 10 additional studies have since been published, including the first randomized controlled trial (RCT). 10,11 We proceeded with this systematic review to provide the most up-to-date assessment of perioperative and long-term clinical outcomes and cost for robotassisted inguinal hernia repair compared with open and laparoscopic approaches. METHODSThis review is part of a larger report commissioned by the Department of Veterans Affairs on the clinical outcomes and cost-effectiveness of robotic procedures for cholecystectomy, inguinal hernia repair, and ventral hernia repair. This systematic review is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, 12 and the a priori protocol was registered in PROSPERO: CRD42020156945.

Clinical outcomes and cost of robotic ventral hernia repair: systematic review

“…The longer operating time for robotic VHR compared with open surgery or laparoscopic VHR is consistent with similar findings for inguinal hernia repair and cholecystectomy 41 , 42 . This is likely related to a variety of factors, including robot docking, surgeon and staff efficiency, learning curve, and patient selection.…”

Early outcomes of robotic transabdominal preperitoneal inguinal hernia repair: a retrospective single-institution study in Korea

“…Several studies have described the successful transition of surgeons from the laparoscopic to the robotic approach, demonstrating its feasibility while being safe [3,5]. Additionally, the number of patients undergoing robotic inguinal hernia repairs continues to increase despite its controversial clinical benefits [6].…”

“…Several studies have described the successful transition of surgeons from the laparoscopic to the robotic approach, demonstrating its feasibility while being safe [ 3 , 5 ]. Additionally, the number of patients undergoing robotic inguinal hernia repairs continues to increase despite its controversial clinical benefits [ 6 ]. However, reports also indicate that longer operative times and higher costs associated with robotic inguinal hernia repair negate its potential benefits [ 6 , 7 ].…”

“…Additionally, the number of patients undergoing robotic inguinal hernia repairs continues to increase despite its controversial clinical benefits [ 6 ]. However, reports also indicate that longer operative times and higher costs associated with robotic inguinal hernia repair negate its potential benefits [ 6 , 7 ]. Furthermore, despite the promising outcomes of robotic inguinal hernia repair, published data are limited to retrospective single-center series, and a quantitative analysis of its potential benefits is lacking [ 2 , 8 ].…”

Trends in Robot-Assisted Procedures for General Surgery in the Veterans Health Administration

“…2 Laparoscopic cholecystectomy, inguinal hernia repair, and ventral hernia repair are the three most commonly performed operations in general surgery and comprise the majority of cases done with the robotic platform, despite uncertain clinical benefits. [3][4][5][6] Studies examining the acquisition and utilization of surgical robotic systems have predominantly focused on the civilian/ private sector and large databases with mixed hospital systems. 1,7,8 Furthermore, the drivers for implementation and its variations across the country are unknown.…”