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