Meta-analysis of the effectiveness and safety of robotic-assisted versus laparoscopic transabdominal preperitoneal repair for inguinal hernia

Clinical and Patient-Reported Outcomes of Robotic Versus Laparoscopic Inguinal Hernia Repair

Background

This study aimed to assess the clinical and patient-reported outcomes of laparoscopic and robotic-assisted inguinal hernia repair in Indian real-world settings.

Methods

This is a single-center, prospective, nonrandomized, comparative study. Consecutive patients who were 18 years of age or older, and provided informed consent were included in the study between June 2023 and May 2024.

Results

In all, 83 patients were prospectively enrolled in this study: 24 patients were in the robotic-assisted surgery (RAS) group and 59 patients were in the laparoscopic surgery (LS) group. The baseline characteristics of the study cohorts were comparable. The mean total operating time for the RAS group was significantly longer than the LS group (89.83 ± 24.31 vs 67.71 ± 18.34 minutes, P = .0000). For the bilateral hernias, the RAS group's total operating time was significantly longer than that of the LS group; however, for the unilateral hernias, there was no discernible difference. Urine retention was the only early complication in 8.33% and 16.95% of patients, respectively, in the RAS and LS groups. The duration of hospital stay did not significantly differ between the 2 groups (P = .395). The pain scores of the RAS group were significantly lower on postoperative days 1, 4, and 7. Patients in the RAS group scored considerably higher on the quality of life (QoL) scale 1 month after surgery than patients in the LS group.

Conclusion

This study reports encouraging preliminary clinical outcomes of RAS inguinal hernia repairs in Indian settings, in terms of postoperative pain and QoL.

Inflammatory response and short-term outcomes after laparoscopic versus robotic transabdominal preperitoneal inguinal hernia repair: randomized clinical trial (ROLAIS)

BACKGROUND

The aim of this study was to compare robotic-assisted transabdominal preperitoneal (R-TAPP) and conventional laparoscopic transabdominal preperitoneal (L-TAPP) inguinal hernia repair with respect to surgical stress response and short-term outcomes.

METHODS

This single-centre, open-label, RCT enrolled patients undergoing elective inguinal hernia repair. Patients were randomized 1 : 1 to R-TAPP or L-TAPP using a computer-generated sequence with block sizes of six. All procedures were performed by the same experienced surgeons. The primary outcome was plasma C-reactive protein (CRP) levels. Secondary outcomes included interleukin 6 (IL-6) levels, operating time, complications, length of stay, and readmission rate.

RESULTS

A total of 150 patients (R-TAPP, 76; and L-TAPP, 74) were randomized, with 11 withdrawing before surgery, leaving 139 (R-TAPP, 74; and L-TAPP, 65) for intention-to-treat analysis. CRP levels were significantly lower after R-TAPP on postoperative days 1 and 3 (reductions of 23% and 32% respectively, P = 0.001). IL-6 levels were also lower after R-TAPP at 30 and 120 min after extubation (reductions of 26% and 22% respectively, P < 0.001). R-TAPP was associated with a shorter operating time (-13.4 min, P < 0.001), fewer complications (23.0% versus 41.5%, P = 0.029), including fewer haematomas (6.8% versus 18.5%, P = 0.043), and a higher same-day discharge rate (95.9% versus 81.5%, P = 0.012). No significant differences were observed regarding chronic pain and recurrence rates.

CONCLUSION

R-TAPP was associated with reduced surgical stress, complications, operating time, and hospitalization compared with L-TAPP. These findings support further multicentre trials to assess long-term outcomes and generalizability.

REGISTRATION NUMBER

NCT05839587 (http://www.clinicaltrials.gov).

Robot-assisted inguinal hernia repair and prostatectomy: safety and outcomes from a retrospective cohort study

Prostate cancer and inguinal hernia frequently coexist in elderly men, with 20-33% of patients undergoing radical prostatectomy also presenting with an inguinal hernia. Combining robot-assisted radical prostatectomy (RARP) with transabdominal preperitoneal (rTAPP) hernia repair offers both clinical and logistical benefits, although concerns regarding mesh-related complications remain. This retrospective cohort study analyzed 40 patients who underwent combined RARP and rTAPP hernia repair between August 2021 and September 2024. The mean operative time was 192.83 ± 32.57 min, with 54.2 ± 16.75 min dedicated to hernia repair. No mesh-related complications, including seromas or hematomas in the inguinal region, were observed. Minor complications (Clavien-Dindo ≤ 2) occurred in 25.64% of patients, with seromas (12.82%) and surgical site infections (7.69%) being the most common. The average hospital stay was 1.9 ± 0.50 days, and no hernia recurrences were noted during a mean follow-up of 16.03 ± 10.32 months. These findings support the safety and feasibility of simultaneous RARP and rTAPP hernia repair, maintaining low complication rates and eliminating the need for additional surgeries. Further multicenter studies are needed to validate these results and assess long-term outcomes.

A Systematic Review of Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Management of Inguinal Hernias in the 21st Century

Background: In the 21st century, the management of groin hernias (GHs) has evolved from watchful waiting (WW) to robotic hernia repair (RHR). The present study interrogates the status of robotics in the context of current repairs and provides one author's perspectives. Methods: A systematic review was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for studies comparing open (OHR) to robotic hernia repair (RHR); RHR to laparoscopic hernia repair (LHR); or OHR vs. LHR vs. RHR. The historical context was extracted from previous reviews. Results: Fifty-four studies were included in the analysis. Three techniques have withstood the test of time: OHR (tissue and mesh repairs), laparo-endoscopic (TEP and TAPP), and RHR. The literature indicates that RHR is safe and effective for the management of groin hernias. Operative times and costs remain a concern when using this technique. While the number of overall complications with RHR is similar to OHR, in a minority of cases, complications are more consequential with the robotic platform. Conclusions: RHR has emerged as an unequivocally powerful technique for the management of GHs. OHR remains the technique of choice for local/regional anesthesia, posterior recurrences, and in centers that lack other platforms. In low- and middle-income countries, OHR is the most utilized technique. Centers of excellence should offer all techniques of repair including WW.

Single-port versus multi-port laparoscopic and robotic inguinal hernia repair: a systematic review and network meta-analysis

BACKGROUND

The evolution of minimally invasive surgery has transformed inguinal hernia repair (IHR). The innovative single-port technique reduces the number of surgical incisions. However, the benefits of single-port IHR remain controversial. Our systematic review and network meta-analysis assess the efficacy and clinical outcomes of single-port laparoscopic inguinal hernia repair (SPL-IHR), multi-port laparoscopic inguinal hernia repair (MPL-IHR), single-port robotic inguinal hernia repair (SPR-IHR), and multi-port robotic inguinal hernia repair (MPR-IHR).

METHODS

A comprehensive search was conducted in PubMed, EMBASE, Cochrane, and Ovid for articles published before January 2024, focusing on complication rates, recurrence, seroma, hematoma, operative time, post-operative pain, and cosmetic outcomes of laparoscopic or robotic IHR. Both extraperitoneal (TEP) and transabdominal (TAPP) approaches were analyzed using MetaInsight. MPL-TAPP was used as the standard for comparison.

RESULTS

Thirty-seven studies, including 5,038 patients, 36.92% (1,860 patients) underwent MPL-TEP, 23.64% (1,191 patients) SPL-TEP, 22.23% (1,120 patients) MPR-TAPP, 10.08% (508 patients) MPL-TAPP, 5.40% (272 patients) SPL-TAPP, and 1.73% (87 patients) SPR-TAPP. There were no significant differences in the rates of post-operative complications, hernia recurrence, hematoma, or seroma among the techniques when compared to MPL-TAPP. For secondary outcomes, MPR-TAPP significantly increased the operative time for unilateral hernia repair by a mean difference (MD) of 10.60 min [95% CI: 2.16-19.04]. Conversely, for bilateral hernia repair, there was no significant difference. Post-operative pain was significantly higher for MPL-TEP and SPL-TEP, with MDs of 1.44 [95% CI: 0.43 to 2.44] and 1.22 [95% CI: 0.18 to 2.26], respectively. SPL-TEP was significantly favored in cosmetic outcomes over MPL-TEP, with an MD of 0.65 [95% CI: 0.07 to 1.24].

CONCLUSION

In our network meta-analysis, the risk of post-operative complications, including recurrence, hematoma, and seroma, does not significantly vary among single-port and multi-port laparoscopic or robotic techniques. This suggests that surgical technique selection can rely on surgeon expertise and resource availability, without compromising outcomes.

Introduction and Short-Term Outcomes of Robot-Assisted Transabdominal Preperitoneal Inguinal Hernia Repair at a Municipal Hospital by a Robotic Surgery Novice: A Single-Center, Observational Study

INTRODUCTION

Robot-assisted transabdominal preperitoneal inguinal hernia repair (RTAPP) has been rapidly gaining popularity. However, RTAPP is currently limited to university hospitals and large medical centers and is performed mainly by experts in robotic surgery in Japan. In this study, we report the introduction of RTAPP at a municipal hospital by a robotic surgery novice and its short-term outcomes.

METHODS

We reviewed the data of patients with inguinal hernias who underwent RTAPP performed by a single surgeon between November 2023 and May 2024 and evaluated its safety and short-term outcomes. A comparative study was conducted using laparoscopic transabdominal preperitoneal inguinal hernia repair (LTAPP) performed by the same surgeon.

RESULTS

We identified 13 lesions in 11 patients (unilateral in nine; bilateral in two) in the RTAPP group. The median operative time for unilateral cases was 137 (interquartile range [IQR], 75-200) min, with a console time of 98 (IQR, 40-156) min. The time for dissection, mesh placement, and peritoneal suturing was 67 (IQR, 44-79), 5 (IQR, 5-7), and 11 (IQR, 11-15) min, respectively. To date, no complications or recurrence has been observed in any of these cases. No significant difference in operational time was observed for unilateral cases between the RTAPP and LTAPP groups (137 min vs. 104; p = 0.129).

CONCLUSION

Our study suggests that RTAPP is safe and feasible, even at a municipal hospital, by a robotic surgery novice. Moreover, RTAPP is comparable to LTAPP in terms of performance.

Reduced risk of recurrence following robotic-assisted TAPP for inguinal hernia repair compared to laparoscopic TAPP: a cohort study of 395 cases

BACKGROUND

Minimal invasive inguinal hernia repair is conducted using among others the laparoscopic transabdominal preperitoneal (TAPP) procedure or the extended totally extraperitoneal (eTEP) approach. Robotic-assisted TAPP (R-TAPP) has recently been introduced as an alternative to laparoscopic TAPP and TEP, and a growing number of robotic-assisted procedures are performed worldwide. The present study was conducted to determine the risk of chronic pain and recurrence associated with the two methods.

METHODS

Three hundred ninety-five patients were retrospectively included in the study and underwent either laparoscopic TAPP (n = 177) or R-TAPP (n = 218). Data on patient demographics, hernia characteristics, and postoperative outcomes were retrieved from medical records. Kaplan-Meier curves and Cox proportional hazards regression were used to assess hernia recurrence. Logistic regression was used to analyze secondary outcomes such as inpatient status, hematoma, and chronic pain.

RESULTS

The Kaplan-Meier curves indicated a consistently higher cumulative incidence of recurrence in the TAPP group compared to the R-TAPP. Consistent with this finding, the Cox regression showed a higher risk of recurrence in patients undergoing TAPP, with a hazard ratio (HR) of 3.489 (95% CI: 1.232 to 9.880, p = 0.019). The E-value for this HR was 6.44, suggesting robustness to unmeasured confounding. There was no difference in the rates of chronic pain between the groups (OR: 1.233, 95% CI: 0.430 to 3.533, p = 0.696). A logistic regression analysis for other postoperative complications revealed no significant differences.

CONCLUSION

This study provides evidence that robotic-assisted TAPP is associated with a lower risk of recurrence than laparoscopic TAPP.