In this observational cohort study with prospectively collected outcomes, we found that robotic repair of moderate-sized, uncomplicated midline ventral hernias was associated with fewer complications, fewer readmissions, and shorter hospital length-of-stay than open repair. This improvement in patient-centric outcomes was largely driven by the avoidance of a midline laparotomy incision with its associated complications. Indeed, not a single infection occurred in the robotic cohort, whereas the open cohort had an 8% surgical site infection rate. Our study design, utilizing strict inclusion criteria, was able to overcome much of the heterogeneity inherent to ventral hernias and produce groups that were comparable both in patient and hernia characteristics. Short of a randomized trial, the contemporaneous treatment of patients in this study and prospective collection of outcomes provided strong evidence that for moderate-sized, uncomplicated midline hernias, robotic techniques offered a clear advantage over open techniques with regard to patient outcomes.
Although both open and robotic techniques achieved a similar technical result—complete fascial closure with reinforcing underlay mesh—we were surprised that the robotic repairs did not take longer to perform. This finding differs from published literature.[9, 11, 12, 19, 20] We were also surprised that patients reported a better hernia-related quality of life after robotic repair in the HerQLes survey given that the end technical result of surgery, i.e., fascial closure with mesh reinforcement, did not differ between groups. We speculate that some of the observed differences in HerQLes score may be related to the effect complications had on patients with regard to longer-term abdominal wall outcomes.
Limitations of this study include its strict inclusion criteria, which were designed to exclude small outpatient repairs (umbilical and epigastric hernias < 3cm) and very large or complex hernias (> 10cm rectus separation, need for concomitant procedure, and so on). Indeed, only 19% of the hernias performed during the study period met our inclusion criteria. As such, our results should not be generalized to all ventral hernias. Additionally, the study design did not randomize patients to robotic or open repair, which was impractical because some surgeons at our center do not perform robotic repairs. Despite the lack of randomization, however, patient characteristics and hernia size were remarkably similar between groups (Table 1, 2), and of studied factors, only open technique was associated with complications (Table 5). An additional limitation is the lack of structured follow-up beyond 30 days in order to ascertain long-term complications and recurrence rates. Unfortunately, we did not have funding for such structured long-term follow up.
Despite the availability of robotic hernia expertise at our center, 40% of uncomplicated, moderate-sized midline ventral hernias that met inclusion criteria were still repaired using open techniques. This reflects a number of factors, including incomplete surgeon training in robotics, patient and surgeon unfamiliarity with robotic techniques, lack of robot block-time availability, and uncertainty about patient outcomes, to name a few. Additionally, the study population represented less than a fifth of the total number of ventral hernias performed at our center over the 5-year period, illustrating the fact that ventral hernias come in all shapes and sizes. Often a concomitant procedure needs to be performed, there is a need for skin incision, there is loss of domain, and so on. These factors may limit the applicability of robotic techniques and as such, we believe that some hernias will likely always need to be performed with an open technique.