Outcomes from 306 consecutive robotic ventral hernia repairs in the community setting
Robotic assisted laparoscopy is an increasingly utilized approach for repair of primary ventral and incisional hernias . A variety of popular robotic techniques allow for a tailored surgical approach to the individual hernia patient . Common robotic techniques include IPOM with fascial defect closure (IPOM +), ventral transabdominal preperitoneal repair (vTAPP), retrorectus (RR) repairs, either by enhanced view totally extraperitoneal (eTEP) or transabdominal access, with or without transverse abdominis release (TAR). Based on the available data, there is an ongoing debate about the indications and benefits of these robotic approaches . This case series of 306 consecutive patients aims to contribute robotic ventral hernia outcomes data from the community hospital setting. 

This is a retrospective analysis of all patients who underwent robotic primary ventral and incisional hernia repairs between January 2022 and December 2023 by a single private practice group of surgeons. The four participating surgeons have each performed a minimum of 1000 robotic cases and have 24/7 access to robotics in a community hospital setting. All patients were seen at 2 weeks in the postoperative period. Further follow up was carried out by phone calls and HIPAA compliant texting with the following questions: (Q1) Do you have any concerns with the surgical area?, (Q2) Have you noticed a new bulge in the surgical area? Any yes, triggered invitation to a clinic for a physical examination and imaging ordered as deemed appropriate. Patient characteristics collected included age, gender, BMI and ASA score. Hernia characteristics were recorded including hernia type and location, defect length and width, mesh length and width, presence of concomitant second hernia, primary vs. recurrent hernia and number of prior repairs. Peri- and postoperative data was collected including: elective vs. emergent cases, console time, case time, intraoperative and immediate postoperative complications, readmissions, reoperations, complications, and hernia recurrence. Participating surgeons performed all robotic hernia repairs with the following reproducible techniques and principles. IPOM + : Laparoscopic direct optical trocar access Clearance of peritoneum and fat from fascia Reduction of hernia sac/contents/preperitoneal fat Fascial defect closure with long-term absorbable suture Permanent synthetic mesh implant with adhesion barrier Minimum mesh overlap of 5 cm in all directions prior to defect closure Mesh fixation with continuous long term absorbable sutures vTAPP (Fig. ): Laparoscopic direct optical trocar access Creation of large peritoneal flap, that can close without any tension Reduction of hernia sac/contents/preperitoneal fat Fascial defect closure with long-term absorbable suture Meticulous closure of any posterior peritoneal defects with absorbable suture Permanent synthetic, monofilament, macroporous mesh implant Minimum mesh overlap of 5 cm in all directions prior to defect closure Mesh fixation with absorbable sutures RR (eTEP) ± TAR (Fig. ). Laparoscopic access of retrorectus space ± ultrasound mapping/guidance Early crossover to opposite retrorectus space at falciform ligament Reduction of hernia sac/contents/preperitoneal fat Full inspection of any herniated bowel (± opening of hernia sac and intraperitoneal inspection as needed) Critical view of TAR , if posterior component separation performed. Complete midline reconstruction with medialization of rectus muscles and anterior fascial defect closure with long-term absorbable suture No posterior fascial closure in this series Meticulous closure of any posterior flap defects Permanent synthetic, monofilament, macroporous mesh implant Mesh reinforces the entire dissected retrorectus space ± TAR space No or minimal mesh fixation with interrupted absorbable suture Transabdominal TAR (Fig. ). Laparoscopic direct optical trocar access Complete adhesiolysis Creation of posterior flaps that rest on the bowel and can be closed without any tension Critical view of TAR  Complete midline reconstruction with medialization of rectus muscles and anterior fascial defect closure with long-term absorbable suture Meticulous closure of any posterior flap defects Permanent synthetic, monofilament, macroporous mesh implant Mesh reinforces the entire dissected retrorectus and TAR space No or minimal mesh fixation with interrupted absorbable suture 

Patient and hernia characteristics This study included 306 patients who underwent robotic primary ventral and incisional hernia repairs as shown in Table . The mean age was 58 years (range 24–87). There were 66.2% male vs. 33.8% female patients. Mean BMI was 31 ± 5. The majority of patients had an ASA score of 2 (59.8%). Of the 306 cases, 63 cases were rIPOM + , 199 cases were vTAPP, and 44 cases were RR repairs ± TAR (either by eTEP or transabdominal access) as shown in Table . There were 200 (65%) primary ventral hernias and 106 (35%) incisional hernias. Almost all hernias were located in the midline (98.7%). In 17.8% of cases, a concomitant 2nd hernia was found intraoperatively. Of the repairs 17% were for recurrent hernias with an average of 1.3 prior repairs (range 1–4). Robotic IPOM + (n = 63) was performed for primary ventral (60%) and incisional hernias (40%), while ventral TAPP was performed mostly for smaller primary ventral hernias (80.4%). There was a small, but statistically significant difference in average hernia width s between these two groups ( 3.2 vs. 2.6 cm, p < 0.001). Retrorecus repairs ± TAR was utilized mostly for incisional hernias (88.6%). When comparing RR repairs without TAR (n = 19) to those with TAR (n = 25), we found that TAR was performed for larger fascial defect widths (4.8 vs. 8.4 cm, p < 0.001). Consequently, larger mesh was utilized in the TAR group (mesh width: 19.1 vs. 26.0 cm, p < 0.001). In the RR ± TAR group, there was a higher number of recurrent hernias (40%) and more complex hernias with up to 4 prior repairs. Perioperative results Almost all cases were performed electively (98%) as shown in Table . Average console and case times for all cases were 75 ± 47 min and 89 ± 49 min, respectively. When comparing IPOM + and vTAPP groups, there was no difference in average console (63 vs. 62 min, p = 0.71) or operative times (77 vs. 75 min, p = 0.58). The RR ± TAR group had much longer average console (151 ± 64 min) and operative times (168 ± 65 min) when compared to IPOM + or vTAPP groups. When comparing RR repairs without TAR to those with TAR, we found that TAR was associated with significantly longer average console (107.8 vs. 184.4 min, p < 0.001) and operative times (127.5 vs. 198.8 min, p < 0.001). There were no conversions to an open procedure in this case series. Intraoperative complications were rare (0.6%) and included a traumatic Foley placement and an episode of ventricular tachycardia in the vTAPP group. Immediate postoperative complications (0.3%) included one patient in the vTAPP group with urinary retention requiring discharge to home with Foley catheter in place. Same day discharge was feasible in most patients: IPOM + (100%), vTAPP (99.5%), and RR ± TAR (68%). Hospital admission was necessary for 14 (56%) TAR patients with an average length of stay of 2.7 days (range 1–8 days). Outcomes All patients were seen 2 weeks postoperatively. Longer term follow up with phone calls and HIPAA compliant texting was achieved in 81% of patients as shown in Table . Of those, 9% answered yes to Q1 and 4% to Q2. In person clinic follow up was completed in 80% of these patients. The average follow up time was 13.3 months (range 6–27 months). The majority of patients were contacted between 12–24 months postoperatively (67.3%). Four patients experienced complications (1.3%). This included a mesh infection after vTAPP repair, requiring robotic removal of the mesh and primary closure of the fascial defect. There was one abdominal wall hematoma after vTAPP repair, which was treated non-operatively and eventually resolved. One patient developed a small trocar site hernia after eTEP Rives Stoppa repair and underwent subsequent elective vTAPP repair of this hernia. The trocar site hernia was located in the linea semilunaris and most likely caused by a technical mistake during initial trocar placement for eTEP access. One patient developed a small bowel obstruction after transabdominal TAR, which was released robotically without further morbidity for the patient. There was no significant difference in complication rates between the IPOM + and vTAPP groups (0 vs. 1.0%, p = 0.96). The overall readmission and reoperation rates were 1.0%, respectively. There were no hernia recurrences in this case series. 

This study included 306 patients who underwent robotic primary ventral and incisional hernia repairs as shown in Table . The mean age was 58 years (range 24–87). There were 66.2% male vs. 33.8% female patients. Mean BMI was 31 ± 5. The majority of patients had an ASA score of 2 (59.8%). Of the 306 cases, 63 cases were rIPOM + , 199 cases were vTAPP, and 44 cases were RR repairs ± TAR (either by eTEP or transabdominal access) as shown in Table . There were 200 (65%) primary ventral hernias and 106 (35%) incisional hernias. Almost all hernias were located in the midline (98.7%). In 17.8% of cases, a concomitant 2nd hernia was found intraoperatively. Of the repairs 17% were for recurrent hernias with an average of 1.3 prior repairs (range 1–4). Robotic IPOM + (n = 63) was performed for primary ventral (60%) and incisional hernias (40%), while ventral TAPP was performed mostly for smaller primary ventral hernias (80.4%). There was a small, but statistically significant difference in average hernia width s between these two groups ( 3.2 vs. 2.6 cm, p < 0.001). Retrorecus repairs ± TAR was utilized mostly for incisional hernias (88.6%). When comparing RR repairs without TAR (n = 19) to those with TAR (n = 25), we found that TAR was performed for larger fascial defect widths (4.8 vs. 8.4 cm, p < 0.001). Consequently, larger mesh was utilized in the TAR group (mesh width: 19.1 vs. 26.0 cm, p < 0.001). In the RR ± TAR group, there was a higher number of recurrent hernias (40%) and more complex hernias with up to 4 prior repairs. 

Almost all cases were performed electively (98%) as shown in Table . Average console and case times for all cases were 75 ± 47 min and 89 ± 49 min, respectively. When comparing IPOM + and vTAPP groups, there was no difference in average console (63 vs. 62 min, p = 0.71) or operative times (77 vs. 75 min, p = 0.58). The RR ± TAR group had much longer average console (151 ± 64 min) and operative times (168 ± 65 min) when compared to IPOM + or vTAPP groups. When comparing RR repairs without TAR to those with TAR, we found that TAR was associated with significantly longer average console (107.8 vs. 184.4 min, p < 0.001) and operative times (127.5 vs. 198.8 min, p < 0.001). There were no conversions to an open procedure in this case series. Intraoperative complications were rare (0.6%) and included a traumatic Foley placement and an episode of ventricular tachycardia in the vTAPP group. Immediate postoperative complications (0.3%) included one patient in the vTAPP group with urinary retention requiring discharge to home with Foley catheter in place. Same day discharge was feasible in most patients: IPOM + (100%), vTAPP (99.5%), and RR ± TAR (68%). Hospital admission was necessary for 14 (56%) TAR patients with an average length of stay of 2.7 days (range 1–8 days). 

All patients were seen 2 weeks postoperatively. Longer term follow up with phone calls and HIPAA compliant texting was achieved in 81% of patients as shown in Table . Of those, 9% answered yes to Q1 and 4% to Q2. In person clinic follow up was completed in 80% of these patients. The average follow up time was 13.3 months (range 6–27 months). The majority of patients were contacted between 12–24 months postoperatively (67.3%). Four patients experienced complications (1.3%). This included a mesh infection after vTAPP repair, requiring robotic removal of the mesh and primary closure of the fascial defect. There was one abdominal wall hematoma after vTAPP repair, which was treated non-operatively and eventually resolved. One patient developed a small trocar site hernia after eTEP Rives Stoppa repair and underwent subsequent elective vTAPP repair of this hernia. The trocar site hernia was located in the linea semilunaris and most likely caused by a technical mistake during initial trocar placement for eTEP access. One patient developed a small bowel obstruction after transabdominal TAR, which was released robotically without further morbidity for the patient. There was no significant difference in complication rates between the IPOM + and vTAPP groups (0 vs. 1.0%, p = 0.96). The overall readmission and reoperation rates were 1.0%, respectively. There were no hernia recurrences in this case series. 

This retrospective case series of 306 consecutive robotic primary ventral and incisional hernia repairs showed a low rate of complications (1.3%), readmissions (1.0%), and reoperations (1.0%). There were no recurrences at an average follow up of 13.3 months (range 6–27 months). In this study, IPOM + was utilized for smaller to medium size (3.2 ± 1.5 cm) primary ventral and incisional hernias, while vTAPP was mostly performed for smaller (2.6 ± 1.0 cm) primary ventral hernias. Retrorectus repairs were performed for medium size (4.8 ± 1.6 cm) primary ventral and incisional hernias. Transverse abdominis release was typically reserved for more complex, recurrent, and larger incisional hernias (8.4 ± 3.3 cm). Our study included experienced robotic surgeons (minimum 1000 cases) and confirmed that robotic efficiency is feasible with the following average console times: IPOM + (63 min), vTAPP (62 min), RR (108 min), RR with TAR (184 min). Preperitoneal dissection during vTAPP can be challenging for medium and larger size incisional hernias due to scar tissue or thin peritoneum. In these situations, IPOM + or RR repairs (either by eTEP or transabdominal access) are typically feasible. During robotic RR repairs, the midline preperitoneal dissection can be challenging due to scar tissue. A large peritoneal defect in the posterior flap might require experience with one of the following techniques: meticulous suturing, mobilization of the hernia sac as a patch, omental patching of the posterior flap defect, intraperitoneal mesh patching, or TAR. Even very large incisional hernias with fascial defect widths up to 16 cm were successfully repaired using TAR technique. During robotic RR and TAR dissections, it is of utmost importance to understand abdominal wall anatomy in order to avoid complications such as denervation of the rectus muscles, semilunar line disruptions, or dissection between the abdominal oblique muscles. In our opinion, achieving the critical view of TAR helps to avoid these complications . There is an ongoing debate about the indications and benefits of the robotic approach for ventral/incisional hernia repair. Multiple meta-analyses comparing robotic vs. laparoscopic repairs are available with varying conclusions. Tran et al. found in an analysis of 39 studies that the robotic approach did not show major benefits when compared to laparoscopic repairs in terms of length of stay, intraoperative complications, and readmissions . The meta-analysis by Peñafiel et al.focused on safety and efficacy outcomes and included four studies with 1293 patients that directly compared robot-assisted versus laparoscopy for incisional hernia repair with a follow up of ≥ 1 month . It did not show any difference in complication rates, but a longer operating time and shorter hospital stay for robotic repairs. The randomized controlled clinical trial by Dhanani et al. included 175 patients and compared 2-year outcomes of robotic vs. laparoscopic IPOM ventral hernia repair . There were no differences in surgical site infections or occurrences. There were more recurrences (4 vs. 13%, p = 0.12) and reoperations (0 vs. 11%, p = 0.019) in the laparoscopic group, showing a potential benefit with robotic repair. The PROVE-IT randomized clinical trial by Petro et al. provided patient reported outcomes of robotic vs. laparoscopic IPOM repair . There were no significant differences in pre and post-operative pain scores, quality of life scores, length of stay, and complication rates. The robotic approach was associated with longer operative time (146 vs. 94 min, p < 0.001). Multiple systematic reviews showed significantly longer operative times for robotic ventral hernia repair when compared to laparoscopic or open repairs . However, there is a variety of robotic techniques and subgroup analysis is required to understand differences in operative times due to procedure and hernia specific complexity. In addition, complex MIS procedures have a significant learning curve to take into account. For example, early reports of robotic vTAPP showed long operative times beyond 2 h . More recent data shows improvement and no significant difference in operative times when comparing robotic vTAPP to IPOM . Kudsi et al. demonstrated a learning curve for robotic vTAPP and showed that it takes approximately 61 cases to consistently decrease operative times . A recent large retrospective Medicare claims study including 161,415 ventral hernia patients reported higher recurrence rates after robotic assisted ventral hernia repair when compared to laparoscopic or open repairs (1). At 2 years, the risk-adjusted cumulative incidence of operative recurrence in the robotic group was approximately 5%, and at 10 years it was 13.43%. Fry et al. discussed that the study likely captured rapid expansion of the robotic approach from specialized centers into the surgical community. A retrospective analysis of 108 robotic ventral/incisional hernia repairs by Sharbaugh et al. showed a recurrence rate of 12% at an average follow up of 21 months . A smaller retrospective review of 31 robotic IPOM repairs showed a recurrence rate of 14.8% at average follow-up of 27 months . Contrary to this, our study from the surgical community showed no recurrences in 306 consecutive primary ventral and incisional hernia repairs at medium-term follow up. Based on our findings, we believe that robotic techniques allow for a tailored approach to the individual hernia patient with the potential for excellent outcomes for most abdominal wall hernias. Limitations of this study include its retrospective design and limited comparability between the robotic techniques utilized due to patient selection and hernia complexity. There were no open or laparoscopic cohorts for comparison. This study included almost exclusively elective patients and outcomes should not be extrapolated to acute/emergent cases. Long-term follow up is needed to assess true recurrence rates. We hypothesize that low hernia recurrence rates can be achieved with robotic techniques, if surgical learning curves are respected, reproducible and sound surgical technique is utilized, familiarity with a variety of robotic hernia repair techniques is achieved, and the robotic system is utilized in most types of primary ventral and incisional hernias in order to avoid selection bias towards higher hernia complexity. 

Robotic ventral hernia repair is a safe and effective strategy for elective treatment of most abdominal wall hernias with low complication and recurrence rates in medium term follow up. Utilizing several robotic techniques allows for a tailored approach based on complexity of the individual hernia patient. Longer term follow up is needed to determine recurrence rates. 

