Laparoscopic, Robotic Repair of Ventral Hernia Yield Similar Patient-Reported Outcomes

By Will Boggs MD

December 01, 2020

NEW YORK (Reuters Health) - Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable patient-reported outcomes, but the robotic approach takes longer and remains more costly, according to results from the PROVE-IT randomized clinical trial.

The robotic platform is increasingly used for hernia repair with intraperitoneal mesh, despite the lack of high-level evidence to support its use.

Laparoscopic repair has been associated with decreased wound morbidity and shorter hospital length of stay, compared with open mesh repair. But laparoscopic intraperitoneal mesh placement has also been associated with rates of chronic pain, bulging and patient dissatisfaction as high as 25%.

Dr. Clayton C. Petro and colleagues of Cleveland Clinic, in Ohio, evaluated whether the robotic approach to ventral-hernia repair with intraperitoneal mesh would result in less postoperative pain, compared with the laparoscopic approach, in their registry-based, single-blind randomized trial of 75 patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less.

All patients achieved fascial closure and mesh placement with adequate overlap adhering to the study protocol. Two patients randomized to the robotic platform were converted to a laparoscopic technique but were treated as robotic patients in the intention-to-treat analysis.

The median pain score (which could range from 0 to 10) on the first postoperative day, the primary outcome, was the same for both laparoscopic and robotic approaches (5 vs. 5, P=0.61), the researchers report in JAMA Surgery.

Similarly, there were no significant differences between the groups in the secondary endpoints of hospital length of stay, same-date discharge, opioid consumption in the postanesthesia-care unit, or overall complication rates.

Pain scores were also similar between the groups on postoperative days 7 and 30, and there were no differences in baseline or postoperative hernia-specific quality-of-life scores.

The median operative time was significantly shorter for laparoscopic operations (94 minutes) than for robotic operations (146 minutes), and the total cost was significantly lower for laparoscopic operations, driven mainly by the difference in the cost associated with operating-room time.

"Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh offer similar early postoperative outcomes in regards to pain, quality of life, and complication rates," the authors conclude. "Owing to the increased operative time and associated cost, there is currently no measurable benefit to justify the robotic approach."

Dr. S. Scott Davis Jr. of Emory University, in Atlanta, Georgia, who coauthored an invited commentary on the findings, told Reuters Health by email, "Despite being around for a little over 2 decades, robotic surgery is really still early in evolution. The machines have improved but still have many ways in which they can be better. The long-standing arguments about ergonomics, surgeon longevity, new surgical-technique development, and improved accuracy are all very real arguments, and they have value that does not appear in a spreadsheet."

"We have to remember that surgeons are still basically remunerated on volume," he said. "Hospitals are volume junkies. They would not be doing robotic surgery if the only outcomes they see were longer operative times and more cost. There is no incentive for them to do that. They are doing it because they feel it offers the patient benefits and that there is real opportunity to achieve efficiency that at least doesn't cost them personally in productivity."

"Unfortunately, in many specialties, high-volume efficient surgeons don't publish, and the publications are more likely to come from surgeons who have not reached those levels of efficiency," Dr. Davis said.

Dr. Jeremy Warren of the University of South Carolina School of Medicine Greenville, who has also compared laparoscopic and robotic ventral-hernia repair, told Reuters Health by email, "Robotic repair is a valid option and should not be discarded as a result of this study, as it confirms the safety and comparable outcomes of this approach."

"More complex patients, particularly those with higher BMI or larger hernia defects, may benefit more from robotic repair due to greater technical challenges of laparoscopic repair in these patients," he said. "Patient and surgeon preference are also important considerations."

Dr. Warren added, "Cost is a nebulous variable and can vary greatly across hospital systems, making this type of cost analysis poorly generalizable. While this may be of critical importance for this institution's decision to support this approach, the equation may be different for surgeons in other systems and may be further magnified by local marketing and referral patterns."

Dr. Frederik Helgstrand of Zealand University Hospital, in Koege, Denmark, previously reported national results after ventral-hernia repair using data from the Danish Ventral Hernia Database. He told Reuters Health by email, "I believe that robotic-assisted ventral-hernia repair may have a role in patients with large hernias with a transverse hernia-defect diameter between 3 and 7-8 cm as an alternative to open repairs and if the mesh is positioned preperitoneal, as an alternative to laparoscopic repair with intraperitoneal mesh position."

"Standard robotic-assisted hernia repair with intraperitoneal mesh position cannot be recommended as alternative to laparoscopic hernia repair," he said. "Robotic-assisted hernia repair has potential, but we still need to identify which patients will benefit."

The study was funded by Intuitive Surgical, which makes surgical robots and had financial ties to several of the authors.

Dr. Petro did not respond to a request for comments.

SOURCE: and JAMA Surgery, online October 21, 2020.