Robotic Hernia Repair No Better Than Traditional Approach, Has Several Drawbacks

By Reuters Staff

March 30, 2020

NEW YORK (Reuters Health) - For primary inguinal hernia repair, there is no apparent benefit to the robotic approach over the traditional laparoscopic approach, according to a randomized controlled trial.

On the contrary, robotic-assisted surgery was pricier, took longer, led to more surgeon frustration and had no ergonomic benefit for surgeons, researchers report in JAMA Surgery.

The robotic platform for inguinal hernia repair has been "rapidly" adopted in the United States, Dr. Ajita Prabhu of the Cleveland Clinic Center in Ohio and colleagues note in their report. But no level-I trials have compared robotic inguinal hernia repair to laparoscopic repair until now.

With funding from Intuitive Surgical, which makes the robots used in the study, the team compared robotic transabdominal preperitoneal repair to standard laparoscopic transabdominal preperitoneal repair in 102 patients (48 in the robotic group and 54 in the control arm).

There were no significant between-group differences in operative outcomes at 30 days in terms of postoperative pain, health-related quality of life, mobility, wound morbidity, or cosmetic outcome.

Robotic hernia repair took longer to perform (median 75.5 min vs. 40.5 min; P<0.001), cost more (median $3,258 vs $1,421; P<0.001), and was associated with greater surgeon frustration on the NASA Task Load Index Scale (32.7 vs. 20.1 on a 1-100 scale with lower scores indicating lower cognitive workload; P=0.004), "without discernible ergonomic benefit for surgeons."

In their report, Dr. Prabhu and colleagues write, "Our study is to date the only prospective randomized head- to-head comparison of robotic vs. laparoscopic minimally invasive inguinal hernia repair. Despite the pilot nature of our study, our outcomes are notable, particularly given the frequency with which inguinal hernia repair is performed in the United States, and suggest that the use of the robotic platform for unilateral uncomplicated inguinal hernia repair is not justified for surgeons able to perform this operation laparoscopically."

They note that their study was not designed to address "potential benefits of the robotic platform for open surgeons attempting to adopt minimally invasive techniques, or in more complex clinical scenarios of inguinal hernia repair and further study should be devoted to these specific questions."

The authors of an invited commentary say the use of the robotic platform for primary inguinal hernia repair has been "controversial." While this study suggests it does not have any benefits over traditional laparoscopy for primary inguinal hernia repairs, "we cannot assume that there is no role for robotic approaches in the field of hernia surgery," write Dr. Jacob Greenberg and Dr. Natalie Liu of the University of Wisconsin School of Medicine in Madison.

"The benefits of 3-dimensional visualization and improved dexterity may prove beneficial in the treatment of recurrent inguinal hernias or postoperative inguinodynia," they point out. "Studies have also shown that robotic surgery is associated with a shorter learning curve and may help transition from open to minimally invasive techniques for surgeons without substantial laparoscopic training."

"While cost still remains a barrier, it may be mitigated with increased competition in the market as new robotic platforms are introduced. Although robotic surgery and laparoscopy may currently be viewed as rivals, the 2 techniques should more accurately be considered as different approaches to facilitate minimally invasive surgery. Surgeons should be mindful of the different costs, risks, and benefits of both techniques and be encouraged to use the approach that provides patients with the best outcomes," the editorial writers conclude.

Several of the authors report financial ties to Intuitive Surgical.

SOURCE: and JAMA Surgery, online March 18, 2020.