Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh

Abstract

IMPORTANCE Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.OBJECTIVE To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain. DESIGN, SETTING, AND PARTICIPANTSA registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.INTERVENTIONS Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh. MAIN OUTCOMES AND MEASURESThe trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost. RESULTSSeventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).CONCLUSIONS AND RELEVANCE Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.

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

“…One non-matched study 24 found a decreased intraoperative complication rate with robotic surgery when the RD was calculated. Intraoperative complication rates for robotic and laparoscopic VHR ranged between 1 and 6 per cent among the three studies 21 , 30 , 36 reporting this outcome and were no different between the approaches ( Table 6 ).…”

“…The remaining two RCTs compared robotic with laparoscopic intraperitoneal onlay mesh (IPOM) repair ( Table 2 ). One 20 was multi-institutional and included 123 patients, and the other 21 included 75 patients at a single institution.…”

“…Seven 12 , 24 , 25 , 32 , 34–36 of eight studies, including all three with propensity matching, demonstrated increased operating time with robotic compared with open surgery by 66–88 min, whereas there was no statistically significant difference in the remaining non-matched study 27 . For the robotic versus laparoscopic comparison, all nine studies 20 , 21 , 26 , 28 , 30 , 31 , 36 , 38 , 40 reporting duration of surgery, including two RCTs and two propensity-matched studies, reported a longer operating time with robotic VHR by a median of 54 min.…”

Postoperative Pain After Robot-Assisted Laparoscopic Ventral Hernia Repair

“…Randomized controlled trials are needed to show that the potential benefits, i.e., shorter operation time, earlier discharge, and less postoperative pain, motivate the costs associated with the robot device. A recently published randomized controlled trial showed that the outcome was equal after robot-assisted and conventional laparoscopic hernia repair, but to greater costs with robot-assisted repair (10). The trial was, however, based on intraperitoneal mesh in both groups, which limits the relative advantage of robotassisted repair.…”

Robotic surgery: is it really different from laparoscopy? a critical view from a robotic pioneer

“…If patients can be discharged the same day, it will be difficult to beat, as costs will be even lower. It may also be a generation thing [29] . The younger surgical generation has not known the struggles and fights to move laparoscopy from open surgery.…”