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

Shouldice Versus TAPP for Inguinal Hernia Repair: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Inguinal hernia (IH) repair is one of the most common surgical procedures worldwide. Among the various techniques available, the Shouldice (SHD) technique is mainly used for nonmesh open repair whereas, the transabdominal preperitoneal (TAPP) approach is a commonly performed minimally invasive method. Despite its widespread use, a direct comparison between the two techniques is lacking. Therefore, this study aims to evaluate the short and long-term outcomes of SHD and TAPP for elective IH repair.

METHODS

We searched the PubMed, Embase, and Cochrane Library on April 16. Mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were pooled for continuous and binary endpoints, respectively. Heterogeneity was assessed with I2 statistics.

RESULTS

Thirteen RCTs comprising 2214 patients were included. Of these, 1089 patients (49%) underwent SHD repair and 1125 (51%) patients underwent TAPP repair. The mean BMI was reported in four studies ranging from 23 to 25.7 kg/m2. Data regarding hernia sizes were not available. Compared with TAPP, SHD significantly reduced seroma (RR 0.20; 95% CI 0.04-0.90; p = 0.04; and I2 = 0%) and increased chronic pain (RR 2.13; 95% CI 1.31-3.46; p < 0.01; and I2 = 0%) and 1-day postoperative pain (MD 2.01; 95% CI 0.72-3.29; p < 0.01; and I2 = 97%). However, there were no significant differences between the groups in recurrence (RR 0.94; 95% CI 0.66-1.35; p = 0.75; and I2 = 12%), hematoma (RR 1.08; 95% CI 0.80-1.46; p = 0.63; and I2 = 0%), urinary retention (RR 0.82; 95% CI 0.49-1.36; p = 0.43; and I2 = 0%), and testicular atrophy (RR 3.28; 95% CI 0.79-13.54; p = 0.10; and I2 = 0%).

CONCLUSION

SHD repair demonstrated a lower occurrence of seromas; however, it was associated with a higher occurrence of both acute and chronic postoperative pain compared to TAPP in patients with a normal BMI. No significant differences were observed between the two techniques in terms of hernia recurrence, hematoma formation, urinary retention, or testicular atrophy rates.

Analysis of hospitalization costs in adult inguinal hernia: based on quantile regression model

BACKGROUND

Inguinal hernia repair is a common surgical procedure with significant variability in hospitalization costs. Traditional cost analysis methods often overlook the distribution of costs across patient demographics and clinical factors. This study employs a quantile regression model to explore the determinants of hospitalization costs for adult inguinal hernia surgery, providing a detailed understanding of cost variations across different quantiles.

METHODS

We analyzed data from adult patients who underwent inguinal hernia surgery at Beijing Chaoyang Hospital from January 2015 to June 2023. The study included patient demographics, hernia-related information, surgery-related details, and cost-related data. A quantile regression model was used to assess the impact of various factors on hospitalization costs at different quantiles (10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%). Data were processed using StataSE 15.0 software.

RESULTS

Our study included 16,602 patients, predominantly male (91.86%) and Han Chinese (96.48%), with the 51-64 years age group being the largest (26.80%). The quantile regression analysis revealed significant cost variations across different quantiles. Younger patients incurred higher costs, with age coefficients ranging from -40.541 at the 90th quantile to -3.082 at the 10th quantile. Uninsured patients faced higher costs, with coefficients from 214.747 at the 80th quantile to 501.78 at the 10th quantile. Longer hospital stays correlated with increased costs, with coefficients from 342.15 at the 80th quantile to 405.613 at the 90th quantile. Patients hospitalized multiple times (≥3) had lower costs, with coefficients from -767.353 at the 40th quantile to -311.575 at the 80th quantile. Comorbidities significantly raised costs, with coefficients for three or more comorbidities ranging from 806.122 at the 80th quantile to 1,456.02 at the 40th quantile. Laparoscopic surgery was more expensive than open surgery, with coefficients from 1,834.206 at the 80th quantile to 2,805.281 at the 10th quantile. Bilateral surgeries and the use of biological mesh also resulted in higher costs, with coefficients for bilateral surgeries ranging from 1,067.708 at the 10th quantile to 2,871.126 at the 90th quantile and for biological mesh from 3,221.216 at the 40th quantile to 6,117.598 at the 90th quantile.

CONCLUSIONS

Hospitalization costs for inguinal hernia surgery are influenced by multiple factors, with significant variations across different patient groups. Strategies to control costs should be tailored to address the specific needs of patients, optimize surgical methods, and improve perioperative care. Future research should extend these findings across different healthcare settings and consider the latest advancements in medical technology and policy changes.

A cost-conscious establishment of a robotic abdominal wall reconstruction program in a publicly funded healthcare system

PURPOSE

Despite reports of better short-term outcomes, the main criticism for the adoption of the robotic surgery platform for abdominal wall reconstruction (AWR) has been the associated cost, especially in countries with a publicly funded healthcare system such as Canada. We describe our experience in implementation of robotic AWR while ensuring cost-effectiveness.

METHODS

This is a retrospective cohort analysis of all patients with ventral hernias ranging between 5 to 15 cm who underwent either open or robotic AWR between January 2020 to August 2022. We reviewed patient characteristics, operative time, post-operative length of stay (LOS), and average cost of surgery.

RESULTS

45 patients underwent open repair and 28 underwent robotic repair in the study period. There was no difference in major patient characteristics between the two groups. Operative time was shorter for open repairs (233.2 ± 96.6 min vs. 299.3 ± 71.8 min, p < 0.001). LOS was significantly longer for open repairs (5 days (interquartile range = 4-6) vs. 2 days (IQR = 1.75-3), p < 0.001) and there were significantly more patients who underwent robotic repair who left hospital in less than 3 days (13.3 vs. 64.3%, p < 0.001). The average overall hospital-based cost for each open repair was $26,952.18 when the cost for equipment, operative time, inpatient hospital stay, and epidural use are accounted for, compared to $17,447.40 for robotic repair ($9,504.78 saving per case).

CONCLUSION

With proper selection of patients based on size of hernia, we demonstrate cost conscious adaptation of the robotic technology to AWR. Our future studies will continue to explore the benefits and limits of this approach in complex hernia repair.

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

Purpose

Robotic hernia repair has increased in popularity since the introduction of da Vinci robots (Intuitive Surgical). However, we lack quantitative analyses of its potential benefits. Herein, we report our initial experience with robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair.

Methods

We retrospectively reviewed the data from patients who underwent R-TAPP inguinal hernia repair with a prosthetic mesh using the da Vinci platform. Data on patient characteristics and surgical outcomes were also collected.

Results

Twenty-one patients (including 20 male patients [95.2%]) with a mean age of 54.1 ±16.4 years and body mass index of 23.8 ± 1.9 kg/m2 underwent R-TAPP inguinal hernia repair. Bilateral hernia repair was performed in two patients (9.5%), and six patients (28.5%) with scrotal hernia underwent R-TAPP hernia repair. A sigmoid colon sliding hernia was present in three patients (14.3%). The mean operation and console times were 91.8 ± 20.4 minutes and 154.5 ± 26.2 minutes, and 61.4 ± 16.9 minutes and 128.0 ± 25.5 minutes for unilateral and bilateral inguinal hernia, respectively. Spermatic vessel injury was identified intraoperatively in one patient. Two minor postoperative complications, postoperative ileus, and wound seroma were reported. The mean duration of hospitalization was 3.8 ± 0.9 days. No recurrence or conversion to open surgery was required.

Conclusion

Our findings suggest that R-TAPP inguinal hernia repair is safe and feasible. Its cost-effectiveness, optimal procedural steps, and indications for a robotic approach require further investigation.

Laparoscopic versus robotic inguinal hernia repair: 1- and 2-year outcomes from the RIVAL trial

INTRODUCTION

Robotic inguinal hernia repair is growing in popularity among general surgeons despite little high-quality evidence supporting short- or long-term advantages over traditional laparoscopic inguinal hernia repair. The original RIVAL trial showed increased operative time, cost, and surgeon frustration for the robotic approach without advantages over laparoscopy. Here we report the 1- and 2-year outcomes of the trial.

METHODS

This is a multi-center, patient-blinded, randomized clinical study conducted at six sites from 2016 to 2019, comparing laparoscopic versus robotic transabdominal preperitoneal (TAPP) inguinal hernia repair with follow-up at 1 and 2 years. Outcomes include pain (visual analog scale), neuropathic pain (Leeds assessment of neuropathic symptoms and signs pain scale), wound morbidity, composite hernia recurrence (patient-reported and clinical exam), health-related quality of life (36-item short-form health survey), and physical activity (physical activity assessment tool).

RESULTS

Early trial participation included 102 patients; 83 (81%) completed 1-year follow-up (45 laparoscopic vs. 38 robotic) and 77 (75%) completed 2-year follow-up (43 laparoscopic vs. 34 robotic). At 1 and 2 years, pain was similar for both groups. No patients in either treatment arm experienced neuropathic pain. Health-related quality of life and physical activity were similar for both groups at 1 and 2 years. No long-term wound morbidity was seen for either repair type. At 2 years, there was no difference in hernia recurrence (1 laparoscopic vs. 1 robotic; P = 1.0).

CONCLUSIONS

Laparoscopic and robotic inguinal hernia repairs have similar long-term outcomes when performed by surgeons with experience in minimally invasive inguinal hernia repairs.

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

INTRODUCTION

Implementation of robot-assisted procedures is growing. Utilization within the country's largest healthcare network, the Veterans Health Administration, is unclear.

METHODS

A retrospective cohort study using data from the Department of Veterans Affairs Corporate Data Warehouse from January 2015 through December 2019. Trends in robot utilization for cholecystectomy, ventral hernia repair, and inguinal hernia repair were characterized nationally and regionally by Veterans Integrated Services Network. Patients, who underwent laparoscopic repairs for these procedures and open hernia repairs, were included to determine proportion performed robotically.

RESULTS

We identified 119,191 patients, of which 5689 (4.77%) received a robotic operation. The proportion of operations performed robotically increased from 1.49% to 10.55% (7.08-fold change; slope, 2.14% per year; 95% confidence interval [0.79%, 3.49%]). Ventral hernia repair had the largest growth in robotic procedures (1.51% to 13.94%; 9.23-fold change; slope, 2.86% per year; 95% confidence interval [1.04%, 4.68%]). Regions with the largest increase in robotic utilization were primarily along the Northeast, Midwest, and West Coast.

CONCLUSIONS

Robot utilization in general surgery is increasing at different rates across the United States in the Veterans Health Administration. Future studies should investigate the regional disparities and drivers of this approach.

Robot-Assisted General Surgery Procedures at the Veterans Health Administration: A Comparison of Surgical Techniques

INTRODUCTION

The use of the robot in general surgery has exploded in the last decade. The Veterans Health Administration presents a unique opportunity to study differences between surgical approaches due to the ability to control for health system and insurance variability. This study compares clinical outcomes between robot-assisted and laparoscopic or open techniques for three general surgery procedures.

METHODS

A retrospective observational study using the Veterans Affair Surgical Quality Improvement Program database. Operative time, length of stay, and complications were compared for cholecystectomy (robot-assisted versus laparoscopic), ventral, and inguinal hernia repair (robot-assisted versus laparoscopic or open) from 2015 to 2019.

RESULTS

More than 80,000 cases were analyzed (21,652 cholecystectomy, 9214 ventral hernia repairs, and 51,324 inguinal hernia repairs). Median operative time was longer for all robot-assisted approaches as compared to laparoscopic or open techniques with the largest difference seen between open and robot-assisted primary ventral hernia repair (unadjusted difference of 93 min, P < 0.001). Median length of stay was between 1 and 4 d and significantly for robot-assisted ventral hernia repairs (versus open, P < 0.01; versus lap for recurrent hernia, P < 0.05). Specific postoperative outcomes of interest were overall low with few differences between techniques.

CONCLUSIONS

While the robotic platform was associated with longer operative time, these findings must be interpreted in the context of a learning curve and indications for use (i.e., use of the robot for technically challenging cases). Our findings suggest that at the Veterans Health Administration, the robot is as safe a platform for common general surgery procedures as traditional approaches. Future studies should focus on patient-centered outcomes including pain and cosmesis.

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

BACKGROUND

Robotic ventral hernia repair (VHR) has seen rapid adoption, but with limited data assessing clinical outcome or cost. This systematic review compared robotic VHR with laparoscopic and open approaches.

METHODS

This systematic review was undertaken in accordance with PRISMA guidelines. PubMed, MEDLINE, Embase, and Cochrane databases were searched for articles with terms relating to 'robot-assisted', 'cost effectiveness', and 'ventral hernia' or 'incisional hernia' from 1 January 2010 to 10 November 2020. Intraoperative and postoperative outcomes, pain, recurrence, and cost data were extracted for narrative analysis.

RESULTS

Of 25 studies that met the inclusion criteria, three were RCTs and 22 observational studies. Robotic VHR was associated with a longer duration of operation than open and laparoscopic repairs, but with fewer transfusions, shorter hospital stay, and lower complication rates than open repair. Robotic VHR was more expensive than laparoscopic repair, but not significantly different from open surgery in terms of cost. There were no significant differences in rates of intraoperative complication, conversion to open surgery, surgical-site infection, readmission, mortality, pain, or recurrence between the three approaches.

CONCLUSION

Robotic VHR was associated with a longer duration of operation, fewer transfusions, a shorter hospital stay, and fewer complications compared with open surgery. Robotic VHR had higher costs and a longer operating time than laparoscopic repair. Randomized or matched data with standardized reporting, long-term outcomes, and cost-effectiveness analyses are still required to weigh the clinical benefits against the cost of robotic VHR.