Robotic Inguinal Hernia Repair: Current Status

Robotic inguinal hernia repair (RIHR) is becoming increasingly more common since its initial description. In the last 5 years short and long term patient outcomes, and specific utility in complex cases such as bilateral hernias, mesh extraction, multiple recurrence, and prior urologic pelvic procedures have become key topics of discussion. This article will serve to review the recent data on these topics, discuss the complex and often conflicting interplay of patient outcomes, education, and cost, as well as highlight future directions and potential for the field of robotic inguinal hernia repair.

General themes of recent studies convey that RIHR is as safe and effective as laparoscopic inguinal hernia repair (LIHR) with a potential trend towards improved outcomes in complex cases such as bilateral or recurrent, is found to have higher cost and longer operative times particularly for uncomplicated unilateral inguinal hernias, and increased level of surgeon frustration. Use of RIHR in emergent cases appears to be safe and effective. There appears to be particular utility for RIHR in patients with prior pelvic urologic procedures such as prostatectomy, inguinal bladder herniation, and artificial urethral sphincter implantation. With regards to cost, RIHR appears to be more expensive on average than LIHR, Although the average direct cost of RIHR was slightly higher than LIHR the average contribution margin for the laparoscopic approach was slightly lower than the robotic approach. Patient selection is key for value. Surgeon learning curve does improve with more cases, and operative times decrease with progression through the curve without significant increases in complication rate. When considering surgical trainees, operative times are increased when trainees are involved. However, times decrease as trainees progress through the curve, and cases involving senior residents have been shown to demonstrate less overall cost per minute for RIHR vs LIHR. Marketing pressure and interest for the field of robotics is a real factor which exerts forces on both hospitals and surgeons for reasons that often have little to do with patient outcomes, and while not overtly sinister, should at least give pause and be acknowledged. While the Intuitive DaVinci system line has been the lone contender in the field of robotics for decades, multiple competitor systems are now entering the market with preliminary studies demonstrating safety and efficacy for RIHR. This will potentially drive down overall cost through market competition.

Robotic inguinal hernia repair remains overall equivalent to laparoscopic inguinal hernia repair with regards to long term outcomes, and is most commonly associated with increased cost versus LIHR. There is potential benefit for RIHR over LIHR in complex cases, such as bilateral and recurrent repairs, cases involving prior pelvic urologic procedures, and emergent cases. Surgeon learning curve is a confounder which appears to result in decreased operative time, complications, and cost as a surgeon progresses through the curve. Trainee education has been associated with increased operative time and cost. As alternative platforms and new platform designs enter the market, the discussion around cost and quality will continue to evolve as the technological economy adjusts to market competition. There is currently no definitive best approach, and in the current climate it is imperative to weigh potential risks and benefits of a robotic approach to inguinal hernia repair on an individual patient basis.