Learning Curves for Robotic-Assisted Ventral Hernia Repair

Abstract

ImportanceAlthough the use of robotic-assisted ventral hernia repairs has increased significantly over the last decade, the experience surgeons need to achieve comparable outcomes with more established laparoscopic and open approaches has not been well characterized.ObjectiveTo estimate the learning curves for robotic-assisted ventral (incisional and umbilical) hernia repair.Design, Setting, and ParticipantsThis retrospective cohort study included Medicare fee-for-service patients (≥18 years) enrolled in Medicare Part A and Part B with no managed care undergoing ventral hernia repairs between 2010 and 2020. Multivariate logistic regression was used to estimate reoperation rates for hernia recurrence, adjusting for patient demographics, comorbidities, mesh placement, and hospital characteristics. Analyses were conducted from October 2023 to July 2024.ExposureIncremental robotic-assisted hernia repair volume.Main Outcome and MeasureReoperation for hernia recurrence within 7 years of index hernia repair.ResultsThis study comprised 160 379 Medicare patients (mean [SD] age, 69 [11] years), of whom 93 272 (58.2%) were female, 13 799 (8.6%) were Black, 3124 (2.0%) were Hispanic, and 138 311 (86.2%) were White. Among these patients, 12 609 (7.9%) underwent robotic-assisted hernia repairs, 32 337 (20.2%) laparoscopic repairs, and 115 433 (71.9%) open repairs. This study also included 23 580 surgeons, with 5074 performing robotic-assisted hernia repairs. The national reoperation rates for hernia recurrence after laparoscopic and open repairs were 12.5% (95% CI, 12.06%-12.94%) and 12.9% (95% CI, 12.70%-13.15%), respectively. Reoperation rates decreased as the number of robotic-assisted cases increased, from 14.2% (95% CI, 13.34%-14.97%) at 10 cases to 7.6% (95% CI, 6.75-8.37) at 50 cases. Surgeons needed at least 19 (95% CI, 16-22) robotic-assisted hernia repairs or 16 (95% CI, 13-19) repairs to achieve outcomes equivalent to those of laparoscopic and open procedures. Few surgeons (285 surgeons [5.7%]) performed enough robotic-assisted ventral hernia repairs to achieve necessary volume nationally to overcome the learning curve.Conclusions and RelevanceIn this cohort study of 23 580 surgeons who performed ventral hernia repairs between 2010 and 2020, increasing experience with robotic-assisted hernia repairs was associated with improved long-term reoperation rates for hernia recurrence. However, the majority of surgeons did not perform enough cases to reach reoperation rates equivalent to more established laparoscopic and open approaches.