Is Robotic Surgery the Future for Abdominal Wall Hernia Repair? Not So Fast

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No great advance has been made in science without disagreement, and robotic surgery is certainly no stranger to such controversy. Over the past 5 years, we have witnessed the popularization of robotic-assisted hernia repair based on the experience of strong, vocal proponents of the technology through innovative dissemination platforms such as social media. The adoption of this technology; however, has far outpaced traditional evidence-based data, leaving many skeptical as to its value. Thus, the study by Carbonell et al is received with great enthusiasm. This study is the first to compare robotic-assisted and open retromuscular ventral hernia repairs using a clinically rich data source—the Americas Hernia Society Quality Collaborative (AHSQC) clinical registry. After propensity score matching, the authors demonstrate a significant 1-day decreased length of stay for patients who underwent robotic-assisted repair (n = 111) versus those who underwent open repair (n = 222). Other than surgical site occurrences which were higher in the robotic assisted group (32% vs 14%; P < 0.001), no difference was demonstrated in 30-day outcomes. Outcomes longer than 30 days and data on costs were not addressed within the study.1
Interestingly, the findings from this study parallel those of a randomized control trial (RCT) published in The Lancet, which directly compared robot-assisted prostatectomy and open radical retropubic prostatectomy.2 The rapid, widespread dissemination of robotic-assisted surgery for prostatectomy is well-recognized. It is estimated that 80% to 85% of all prostatectomies within the United States are performed in a robotic-assisted fashion, yet before this study, robust level 1 data were not available to support this approach. The published RCT was the first of its kind to perform a direct comparison between the techniques. Outside of decreased length of stay for patients undergoing robotic-assisted prostatectomy, 12-week trial results demonstrated no difference in functional outcomes between techniques and a similar perioperative safety profile.1 Despite the near-uniform adoption, acceptance, and enthusiasm for robotic-assisted prostatectomy, the authors concluded that: “patients should choose an experienced surgeon they trust and with whom they have rapport, rather than a specific surgical approach.” Longer-term data on cancer survival and other potential benefits were not addressed at 12 weeks, but will be made available at the completion of the clinical trial which has a 2-year endpoint.
The notion that experience and capability, rather than a specific technique, drive operative outcomes is critical. Although I commend Dr Carbonell and the authors on their high-quality work, at the end of the day, no benefit to robotic-assisted hernia repair was demonstrated outside of a 1-day decrease in hospital length of stay. It is also unclear as to whether the 1-day benefit was secondary to the robotic technique, or to other factors such as enhanced recovery pathways and institutional variability which are not captured in the propensity score analyses. Even if the 1-day difference in length of stay could clearly be attributed to the robotic technique, one may question whether this finding is significant enough to support the widespread application of robotics to hernia repair. Although the authors prepared a compelling cost argument, the value of 1 day in the grand scheme of hernia treatment is questionable. The true measure of patient benefit after hernia repair can only be determined via long-term outcomes assessing durability and abdominal wall function. Thus, in the absence of cost data and longitudinal outcomes, interpreting the value of this technique is not possible.
Additionally, there are also concerns as to whether the findings of this study are applicable and reproducible over a larger population of more diverse surgeons.
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