Should we go robotic for inguinal hernia repair?

Carlos E Costa Almeida
há 4 dias
3 min de leitura

Inguinal hernia repair is one of the most frequently performed procedures worldwide. Men have a higher risk of developing inguinal hernia than women (27-43% vs 3-6%). For the last years, laparoscopic inguinal hernia repair has gained wide acceptance among surgeons because of the associated faster recovery and less postoperative pain. I perform laparoscopic transabdominal preperitoneal (L-TAPP) repair as a standard, excluding some patients submitted to previous multiple laparotomies or radical prostatic treatments. I am using three ports, a Progrip self-fixating mesh from Medtronic, and a V-LOC suture for closing the peritoneum flap. Usually, I do not use tackers for extra fixation. Recovery is faster and easier after L-TAPP compared to the anterior open approach; this is a sustained truth.

In the present day, robotic-assisted inguinal hernia repair is gaining supporters. The potential advantages of robotic inguinal hernia repair over the laparoscopic repair will be less evident than the laparoscopic approach over the open approach, I think. Robotic-assisted repair is also a laparoscopic approach; the difference is using a robot as an interface. Is robotic-assisted transabdominal preperitoneal (R-TAPP) better than L-TAPP? Will the patients benefit from using the robot? Should we invest in robots for hernia surgery?

Is robot the future? Robotic surgery versus laparoscopic surgery.

First, L-TAPP is associated with some bad body standings by surgeons, causing pain and discomfort during surgery. During R-TAPP, surgeons operate in a comfortable position during the entire surgery. This comfort position will lower the anxiety and stress for the surgeon, allowing a higher concentration level during the entire procedure. So, if it is good for the surgeon, it is beneficial for the patient.

Secondly, according to the ROLAIS study (single-center randomized clinical trial) published in March 2025 in the BJS by Dr. Alexandros Valorenzos et al. from Denmark, R-TAPP (with the DaVinvi Xi® System) is associated “with reduced surgical stress, complications, operating time, and hospitalization compared with L-TAPP”. The authors used the Progrip self-fixating mesh and V-LOC suture for all patients. Although these data are coming from a single center, they are very important. The authors analyzed and compared 74 patients submitted to R-TAPP with a group of 65 patients submitted to L-TAPP. Patients were randomized to each group between October 2022 and April 2024. Both groups were identical according to BMI, gender, smoking status, previous open abdominal surgery, and previous laparoscopic abdominal surgery. The authors concluded for less surgical stress because both CPR (p=0.0001) and IL-6 (p<0.0001) levels were lower in the R-TAPP group. Operating time was statistically lower for robotic-assisted inguinal hernia repair (p<0.0001). The same was noted for complications (p=0.029) and postoperative hematomas (p=0.043). However, although there was no statistical significance, there was one bowel perforation and one hernia recurrence in the R-TAPP group and none in the L-TAPP group. On the contrary, L-TAPP was associated with one port hernia, while there was none in the R-TAPP (no statistical significance). So, it is easy to understand that R-TAPP had a higher same-day discharge rate than L-TAPP, 95.9% vs. 81.5% (p=0.012).

Third, the same authors concluded R-TAPP and L-TAPP had no differences regarding chronic pain.

This work supports the hypothesis that “robotic surgery minimizes tissue trauma through precise dissection”. However, in complex cases, this effect was not statistically noted. Additionally, the authors state that this lower stress (lower CPR and IL-6) was associated with “the use of the robotic platform itself and not mediated by a potentially overestimated duration of L-TAPP”. As the authors say, this biochemical advantage of R-TAPP is important because it is associated with clinical benefits for the patients compared to L-TAPP. It is interesting to see the lower rate of complications in R-TAPP, contrasting with other studies that showed no differences. Dr Alexandros et al. justify this data with the retrospective nature of other studies, likely to “under-report complications”. Drawbacks of this study are the open-label design (surgeons were not "blinded"), small sample, and single-center trial. However, it is a study to consider because the authors included “bilateral, inguinoscrotal, and recurrent hernias, reflecting real-world clinical practice”. This is not a selected-patients trial.

Therefore, it appears that R-TAPP yields better short-term results and comparable long-term results to L-TAPP. It looks like robotic-assisted inguinal hernia repair is here to stay, at least when using the DaVinci Xi® System. Will the results be the same with other platforms? Are all robotic platforms equal in terms of capabilities? Can we go full-robotic with any other platform? That is another question…

Disclosure: I have no conflicts of interest, and I am not performing robotic surgery.