Robotic ventral hernia repair

INTRODUCTION — Ventral hernias are a common problem: one-third of all patients have a ventral hernia on examination, and one-half have a ventral hernia on radiologic evaluation [1,2]. Of these, two-thirds are primary ventral hernias and one-third are incisional hernias [3].

Ventral hernias range in size from very small defects to large disruptions of the abdominal wall musculature. In addition to size, the anatomical location of the hernia along the ventral abdominal wall also varies (figure 1).

Although less common, incisional hernias remain prevalent and are more complex than primary ventral hernias, mainly because previous abdominal surgery leads to intra-abdominal adhesions that may need to be addressed in the course of hernia repair. In addition, each surgical intervention at a particular site leads to decrements in tensile healing strength, which increases the risk of recurrence [4].

Given the heterogeneity of the disease, management of ventral hernias should be tailored to patient factors, hernia characteristics including size and location, and surgeon experience. Signs and symptoms, including pain or discomfort, disfigurement, and the risk of bowel incarceration or strangulation, usually prompt operative intervention. Each year, over 610,000 ventral hernia repairs are performed in the United States, at an estimated cost of $9.7 billion dollars annually [5].

Ventral hernias may be repaired through either a minimally invasive or open approach. Laparoscopic ventral hernia repair was introduced in the 1990s. In 2003, the first robotic ventral hernia was described in a porcine model [6]. In 2012, the first series of robotic ventral hernias in humans was reported [7]. As general surgeons are increasingly adopting robotic surgery, there is substantial interest in harnessing the potential advantages of the robotic platform for ventral hernia repair, in particular for complex cases. Since then, the application of robotics in ventral hernia repair has grown steadily; as an example, the use of robotic ventral hernia repair increased from 0.5 to 22.4 percent from 2012 to 2018 in Michigan according to data from the Michigan Surgical Quality Collaborative [8].

The indications, contraindications, techniques, and outcomes of robotic ventral hernia repair are discussed here. The clinical features and diagnosis of ventral hernias, the techniques of open and laparoscopic ventral hernia repair, and the use of component separation techniques are discussed in other topics:

●(See "Overview of abdominal wall hernias in adults".)

●(See "Clinical features, diagnosis, and prevention of incisional hernias".)

●(See "Management of ventral hernias".)

●(See "Laparoscopic ventral hernia repair".)

●(See "Overview of component separation".)

●(See "Robotic component separation techniques".)

INDICATIONS — Acutely incarcerated or strangulated ventral hernias require emergency surgical repair. Treatment strategies for chronically incarcerated or reducible ventral hernias include expectant management (watchful waiting), initial medical optimization, or planned surgical repair. The choice is dependent upon (1) patient health state, (2) impact of the hernia on patient quality of life, (3) hernia complexity and probability of a "successful" long-term outcome, (4) risk of acute presentation (ie, bowel obstruction), and (5) patient and surgeon preference (table 1). This process of decision making is discussed in this algorithm (algorithm 1) and another topic. (See "Management of ventral hernias", section on 'Reducible or chronically incarcerated ventral hernias'.)

Occult hernias, or hernias seen on radiographic imaging but not noted on clinical examination, require special attention. Very little data exist to guide us on the natural history and treatment outcomes of occult hernias. Therefore, at this given time, occult hernias should be cautiously managed using the same decision-making factors as for clinical hernias. Early elective surgical repair of occult hernias should be considered for symptomatic patients who are low surgical risk and also for patients at high risk for acute presentation.

Robotic repair has been used for various types of symptomatic ventral hernias. The general indications and selection of minimally invasive versus open ventral repair are discussed in detail separately. (See "Management of ventral hernias", section on 'Surgical management of ventral hernias'.)

CONTRAINDICATIONS

Absolute — The only absolute contraindication for robotic ventral hernia surgery is patient intolerance to pneumoperitoneum. Patients with certain cardiopulmonary conditions may not tolerate pneumoperitoneum.

Relative — Relative contraindications for robotic ventral hernia surgery are related to anatomical factors or comorbid conditions of the patient. These include:

●Prior open abdominal surgery – The level of surgeon experience should be considered before undertaking robotic ventral hernia repair in patients with prior abdominal surgery. Patients with surgical histories that include previous minimally invasive surgery, such as cholecystectomy or appendectomy, may be candidates for robotic ventral hernia repair. However, patients with more extensive surgical histories that include open laparotomies, intra-abdominal sepsis, or abdominal trauma will present more of a challenge for the robotic approach. Lysis of intra-abdominal adhesions will be required, and, while this may be facilitated through the use of the robotic platform, it will require skill and experience. In addition, attention to careful port placement will be required in order to avoid visceral organ injury. Extra operative time will need to be allotted to these patients.

●Recurrent or complex ventral hernias – The level of surgeon experience should also be considered when addressing recurrent ventral hernias robotically. The robotic approach may be advantageous in the surgical treatment of these hernias as it can be used to facilitate lysis of adhesions, removal of any previously placed mesh, and exploration of the hernia defect. However, adequate skill and patience are required to perform recurrent repairs while avoiding intestinal injury and maintaining integrity of the abdominal wall. Particularly complex cases may benefit from an open approach (eg, hernias >10 cm or with loss of abdominal domain). (See "Management of ventral hernias", section on 'Large (width >10 cm) or complex hernias'.)

●Redundant skin and soft tissue – Patients with large ventral hernia defects may have a large amount of redundant skin that will require excision in conjunction with hernia repair. In addition, large ventral hernias with thinning of the overlying skin may have limited blood supply to the flaps once the hernia is reduced. If a skin incision is going to be required for treatment of these soft tissue problems, then consideration should be given to an open approach unless it is felt that a robotic approach would be advantageous for addressing intra-abdominal issues.

●Cirrhosis with collateral circulation and/or ascites – While cirrhosis in itself is not necessarily a contraindication to a minimally invasive approach, port placement will require attention to the presence of abdominal wall varices (ie, Caput medusa). The presence of ascites may require a postoperative plan for reducing ascites while the incisions heal (ie, drain placement or serial paracenteses). (See "Management of ventral hernias", section on 'Cirrhosis'.)

●Strangulated or acutely incarcerated hernias – We suggest an open repair for strangulated or acutely incarcerated ventral hernias. A robotic approach may be appropriate depending on surgeon experience and availability of the robotic platform for emergency cases. In cases of bowel compromise, bowel resection and anastomosis may be performed robotically or accomplished by externalizing the affected portion of intestine. In cases where contamination has occurred, the best treatment strategy is unclear (eg, suture repair, synthetic mesh, biologic mesh, or bioabsorbable mesh repair). (See "Management of ventral hernias", section on 'Contaminated field'.)

SURGICAL APPROACHES — Ventral hernias may be repaired through either a minimally invasive or open approach. In general, for patients at increased risk for surgical site infection such as those with obesity, and when safe and feasible, a minimally invasive ventral hernia repair is preferred over an open repair. However, not all ventral hernias can be performed using a minimally invasive technique due to complexity of adhesions, abdominal disfigurement requiring cosmetic reconstruction, or contamination. The choice of surgical approaches is further discussed elsewhere (algorithm 1). (See "Management of ventral hernias", section on 'Surgical management of ventral hernias'.)

Multiple randomized trials have assessed open versus laparoscopic ventral hernia repair. While long-term hernia recurrence rates are similar between both approaches, laparoscopic ventral hernia repair is associated with substantially lower risk of surgical site infection. There is a slightly increased risk of enterotomy and missed enterotomy with laparoscopic repair compared with open repair. (See "Management of ventral hernias", section on 'Open versus laparoscopic repair'.)

The choice between laparoscopic and robotic ventral hernia repair techniques is much less clear cut. Given the limited and evolving prospective data that distinguish the two minimally invasive techniques, the choice between laparoscopic and robotic repair should be made based upon surgeon expertise, availability of equipment, and surgeon/patient preference (shared decision making).

Currently, arguments for or against robotic ventral hernia repair are both theoretical rather than evidence based:

●Proponents of robotic surgery argue that the robotic platform may allow for a minimally invasive approach for ventral hernia repair that may not be feasible with laparoscopy alone. Given the potential benefits of robotic surgery, including improved optics (three-dimensional camera), increased degrees of freedom, and improved ergonomics, robotic surgery is an appealing approach for many surgeons. This added functionality may allow for the use of robotic surgery as an approach to particularly complex ventral hernias that may be too technically challenging for a laparoscopic approach. Additionally, a 2019 systematic review and meta-analysis of robotic abdominal wall surgery concluded that for ventral hernias that would normally require an open approach, the robotic approach decreases length of stay significantly [9]. Robotic surgery is, however, associated with higher hospital costs than the other two approaches. For the more complex cases, the increase in time spent in the operating room and the higher costs associated with robotic ventral hernia surgery may be offset by this reduction in length of stay [10,11].

Another purported advantage of robotic ventral hernia repair over laparoscopic repair is the potentially improved ability to close the ventral hernia defect. Traditionally, laparoscopic repair did not include this step, and defect closure has remained a debated step of laparoscopic ventral hernia repair [12-15]. Defect closure is a standard part of robotic ventral hernia repair. Multiple randomized controlled trials have demonstrated both short- and long-term benefits for fascial closure, including decreased bulging and improved patient-reported outcomes [16-18]. However, no differences in hernia recurrences have been reported. Finally, large database studies suggest that robotic ventral hernia repair can decrease hospital length of stay in comparison with laparoscopic repair but remains more expensive [19].

●Detractors of robotic surgery argue that high-quality studies have shown that robotic surgery adds cost and operative time with no clinical benefit [20]. In addition, most research published on robotic ventral hernia repair is either at high risk for bias due to study design or is funded by the robotic industry. Authors receiving $10,000 or more from the robotic industry are 200 percent more likely to publish results favorable to the robotic industry [21,22].

PREOPERATIVE PREPARATION

●Obtain informed consent. This should include consent for use of mesh. In addition, this should include a frank discussion regarding risk of hernia recurrence, which can be as high as 37 percent for primary ventral hernias and 64 percent for incisional hernias at 10 year follow-up [23]. Although the 10 year recurrence rate of robotic ventral hernia repair is yet to be reported, it probably would be similar to that of laparoscopic ventral hernia repair.

●Prophylactic antibiotics should be administered within one hour prior to skin incision (table 2). Venous thromboembolism prophylaxis should include serial compression devices with or without pharmacologic prophylaxis.

●How to decompress the bladder is at the surgeon's discretion. While the patient can be asked to void right before the start of a case, consideration should be given to placement of a Foley catheter when a higher level of complexity is anticipated.

●In order to reduce operating room costs for robotic cases, attention should be paid to eliminating all unnecessary disposable equipment. For example, disposable trocars, the suction irrigator, and the vessel sealer should be available but only opened on a case-by-case basis. Likewise, robotic ventral hernia repair can easily be performed with three robotic instruments (scissors connected to monopolar cautery, needle driver, and grasper), thereby limiting the charges associated with the use of each robotic instrument.

SURGICAL TECHNIQUES — In minimally invasive ventral hernia surgery, placement of mesh is an essential step. Consequently, the available techniques of robotic ventral hernia primarily differ from one another in how the mesh is placed:

●The intraperitoneal onlay mesh (IPOM) technique does not require any dissection of the abdominal wall. However, IPOM requires the use of a coated mesh to prevent adhesion to the underlying intra-abdominal structures. (See 'Intraperitoneal onlay mesh' below.)

●The other three techniques, preperitoneal, retrorectus, and retrorectus with transversus abdominis release (TAR), all require additional dissection of the abdominal wall but in different tissue planes. The additional dissection allows for positioning of the mesh within a natural layer of the abdominal wall serving as a barrier against intestine-mesh adherence; and for this reason, a coated mesh is not required. It is our practice to place a mid-density polypropylene mesh in this setting.

Proponents of IPOM argue that the technique involves less tissue dissection and allows for extremely wide mesh overlap. Alternatively, proponents of preperitoneal, retrorectus (including extended view totally extraperitoneal [eTEP] eTEP), and TAR believe that meshes placed in these locations may allow for superior tissue integration (tissue and cells can infiltrate from both sides), which in turn could potentially lead to fewer infections or hernia recurrences [24]. In addition, it is believed that less expensive uncoated meshes can be safely placed in these locations (ie, no antiadhesion barrier needed).

While network meta-analysis of randomized controlled trials of open and laparoscopic ventral hernia repair weakly supports some of these claims [25], the first randomized robotic trial has been reported. In the REVEAL trial, which randomly assigned 100 patients to either robotic eTEP or robotic IPOM repair of midline ventral hernia ≤7 cm, there was no difference in pain at postoperative day 7 or 30 [26]. As expected, robotic IPOM required less surgeon workload and shorter operative time (107 versus 165 minutes) than robotic eTEP repair. Because the mesh is not in contact with the intra-abdominal space during eTEP repair, coated mesh is not required, which constitutes a potential cost saving for eTEP. However, this was offset by the longer operative time and greater utilization of robotic equipment in this study. Additionally, eTEP repair was associated with a higher rate of surgical site occurrences, including seroma and wound cellulitis.

The four available techniques of robotic ventral hernia repair are described below (table 3). Selection of technique depends primarily on the size of hernia defect, ability to close the defect, and level of surgeon expertise. As an example, surgeons who are trained and experienced in the TAR technique may be able to offer patients this type of minimally invasive repair rather than an open procedure. Hybrid techniques, in which portions of the procedure are performed robotically and others are done laparoscopically or open, are also an option in cases where complex defects may benefit from a combination of approaches.

Intraperitoneal onlay mesh — IPOM involves closure of the hernia defect followed by intraperitoneal mesh placement over the defect affixed to the abdominal wall using sutures or tacks. The IPOM technique can be used to repair primary or incisional ventral hernia at any location (midline or off-midline) that is up to 8 to 12 cm. It is the easiest robotic ventral hernia repair technique to learn as it is essentially the same as laparoscopic ventral hernia repair, save for mesh fixation.

Mesh size should be selected to adequately cover the closed defect with at least 5 cm of overlap in all directions. In general, the size of the mesh is selected based upon the original defect size, rather than the size once the defect is closed. However, this has not been thoroughly explored yet. It is our practice to use a synthetic bilayer mesh that includes a coating to prevent adherence to underlying intra-abdominal structures.

Our technique of robotic IPOM ventral hernia repair is presented in detail below and illustrated by this video clip (movie 1).

●Patient positioning – Patients should be positioned supine with both arms thoroughly padded and tucked at the sides. In some cases, positioning of one arm on an arm-board may be advantageous depending on location of the hernia and planned position of the ports. Positioning of the patient with the bed in slightly flexed position will have the effect of creating additional space between the iliac crest and the costal margin, thereby opening up the anterior abdominal wall for port placement. Following placement of the ports, positioning of the bed depending on exact location of the hernia, in Trendelenburg or reverse Trendelenburg, may facilitate exposure. Likewise, rotating of the bed so that the patient is slightly right side up or left side up may provide additional exposure. Initial laparoscopic evaluation prior to docking of the robot will help to guide bed positioning.

●Abdominal entry – Initial abdominal entry may be accomplished either by Veress needle, direct Hassan open cutdown, or via an optical trocar, depending upon surgeon preference. Our preference is entry in the upper quadrants with an optical trocar. Insufflation of the abdominal cavity and visualization of the peritoneal space upon introduction of a laparoscope confirm adequate initial port placement. Pneumoperitoneum should be maintained at 15 mmHg initially but can be decreased later in the case to facilitate closure of the hernia defect.

●Port placement – Port placement will depend on exact location and size of the hernia defect. Traditional port placement for a midline midabdominal ventral hernia includes three ports along the patient's right or left side (picture 1). The ports should be spaced approximately 10 cm apart. Once the hernia is identified laparoscopically, the edge of the fascial defect is marked. In anticipation of at least 5 cm of mesh coverage, the ports should be placed at least 10 cm from this edge. In cases in which the hernia is located in the lower abdomen or epigastrium, consideration can be given to placement of the ports along the upper abdomen or lower abdomen, respectively.

●Docking of the robot – Positioning of the robotic system depends on room setup and the type of platform being utilized. Side docking in parallel or perpendicular position is generally used. Docking from the right or left side of the patient will depend on the laterality of port placement. For certain robotic systems that allow for complete rotation of the robotic arms, docking of the robot can be achieved from either side of the patient regardless of port position or hernia site (picture 2).

●Identification of hernia defect – For primary ventral hernias, the hernia defect is generally readily apparent and requires little to no lysis of adhesions. However, the peritoneum, hernia sac, and preperitoneal fat should all be reduced and excised to fully expose the fascial defect. Often, the hernia content will be preperitoneal fat only. And if this is left behind, patients may complain of a persistent bulge or pain. For incisional or recurrent hernias, lysis of adhesions is often required to expose the hernia defect. Lysis of adhesions can be accomplished using robotic scissors, aided with the cautious application of electrocautery. Inadvertent thermal injury to the bowel can cause immediate or delayed bowel injury. Once the fascial defect has been identified, all hernia contents should be reduced. Gentle application of external pressure on the hernia by a bedside assistant may be helpful. Adhesions between the hernia contents and the hernia sac may require careful dissection for complete reduction.

●Closure of hernia defect – Once the fascial edges have been exposed, the defect can be closed (primary fascial closure). We use a slowly absorbable barbed suture in a running fashion to approximate the fascial edges. The insufflation pressure is reduced to 8 to 10 mmHg in order to reduce tension on the closure. Often, several layers of suture are placed to reinforce closure. The fascia should be closed in the direction that creates the least amount of tension; we close the fascia longitudinally more often than transversely. There are no data to suggest the superiority of either direction.

●Placement of mesh – Positioning of the mesh involves placement of sutures at the four corners of the mesh and one in the center. These sutures are placed prior to introduction of the mesh into the abdomen. Using a suture passing device, these sutures are pulled transfascially through the abdominal wall and held in place while the mesh is affixed to the abdominal wall. The mesh can then be either sutured or tacked circumferentially to the abdominal wall; suturing is technically more demanding than tacking the mesh. It is the authors' practice to suture the mesh using absorbable barbed suture. Alternatively, commercially available positioning devices or systems are available to hold the mesh in proper positioning. In addition to circumferential sutures, a double crown technique may be employed in which an additional ring of sutures or tacks is placed to promote mesh apposition to tissue. In some cases, application of sutures or tacks along the defect closure is employed, again to facilitate tissue adherence. (See "Laparoscopic ventral hernia repair", section on 'Mesh fixation'.)

●Removal of all needles and closure of port sites greater than 8 mm – All port sites greater than 8 mm are closed with a suture-passer. Closure of the 8 mm ports is at the surgeon's discretion. One author does not routinely close these sites, while the other author routinely closes these sites with a suture passer.

Preperitoneal/pretransversalis fascial mesh placement — This technique involves careful dissection for the purpose of creating a peritoneal/transversalis fascia flap around the area of the hernia, followed by defect closure. A piece of mesh is then placed into this natural pocket. The mesh can be affixed in this space with sutures, tacks, or biologic glue. The peritoneal/transversalis fascial flap is then closed with sutures (movie 2).

This technique can be used to repair primary or straightforward incisional ventral hernias that are <4 cm. It requires an intact layer of peritoneum/transversalis fascia, which may not be available in all patients. Lateral, suprapubic, and subxiphoid hernias are most amenable to preperitoneal repair; some midline hernias can also be repaired with this technique. If the dissected peritoneal layer is too thin to provide for mesh coverage, the IPOM approach should be used instead.

Ideally, for a given defect, the same sized mesh should be used for preperitoneal repair as for IPOM repair. However, surgeons are often limited by the size of preperitoneal pocket that can be created to seat the mesh. Therefore, we aim for at least a 3 cm overlap in all directions for preperitoneal repair instead of the 5 cm overlap for IPOM repair.

We do not use transfascial sutures to fix mesh placed preperitoneally. Sometimes we place a few holding sutures to keep the mesh in place while we close the pocket.

Retrorectus mesh placement — This technique involves incision of the rectus sheath and dissection of the retrorectus space to create flap(s). Following dissection from semilunar line to semilunar line, the anterior fascia is closed. Mesh sized to fill the retrorectus space is positioned in the correct tissue plane, followed by closure of the posterior rectus fascia. This approach can be achieved by entering the retrorectus space from the midline or from the semilunar line (extended view totally extraperitoneal). (See "Robotic component separation techniques", section on 'Robotic Rives-Stoppa retrorectus dissection'.)

The retrorectus approach is appropriate for midline primary or incisional hernias with smaller defects, <6 to 8 cm, in which the surgeon would like to avoid intra-abdominal placement of mesh. For defects of larger size, a TAR may be required in order to achieve defect closure and tension-free closure of the posterior rectus fascia. The retrorectus repair with or without TAR is technically more difficult to perform than IPOM and preperitoneal repair.

Extended view totally extraperitoneal — A new approach to robotic ventral hernia repair, the eTEP approach, has also been introduced [27,28]. This approach can be utilized robotically or laparoscopically and involves dissection of the retrorectus space without entry into the peritoneal cavity. Selective utilization of a TAR for larger defects can also be achieved using this approach. Further data regarding the advantages, risks, and ideal patient population for this approach are needed. (See "Robotic component separation techniques", section on 'eTEP approach'.)

Retrorectus with transversus abdominis release — This technique is an extension of the retrorectus approach and initially proceeds as described above. However, just medial to the linea semilunaris, the posterior rectus fascia and transversus abdominis muscle are divided, thereby releasing the posterior rectus sheath and creating a plane between the transversalis fascia and the transversus abdominis muscle (figure 2). This allows for medialization of the posterior rectus fascia for closure of large ventral hernia defects. This technique often requires bilateral port placement and re-docking of the robot. Alternatively, one side can be completed laparoscopically and the contralateral side performed using the robotic platform. The retrorectus/TAR technique can be used to repair primary or incisional hernias with larger defects (>6 to 8 cm) at either midline or off-midline locations. (See "Robotic component separation techniques", section on 'Robotic TAR'.)

OFF-MIDLINE HERNIA REPAIR — The majority of ventral hernias occur in the midline; however, parastomal, Spigelian, and flank hernias are additional types of hernias that fit into this category. These hernias may also be approached robotically. Similar to midline hernias, these hernias can be treated using an intraperitoneal onlay mesh (IPOM) approach as well as a preperitoneal or retrorectus with a transversus abdominis release (TAR) approach. Port positioning will need to be adjusted for the approach to these hernias:

Spigelian hernia — For the Spigelian hernias, ports should be placed along the upper abdomen to allow visualization and treatment of both sides (occult Spigelian hernias are common). (See "Spigelian hernias", section on 'Minimally invasive Spigelian hernia repair'.)

Flank hernia — For flank hernias, patient positioning is important, and proper planning in these situations is essential. Placing patients in partial decubitus or completely lateral secured by a vacuum pack bean bag is often needed. (See "Lateral abdominal wall hernia repair".)

Parastomal hernia — Parastomal hernias present unique challenges. In some cases, the robotic approach may be favorable to an open approach as it facilitates visualization and access that may be otherwise limited. Parastomal hernias are usually repaired by one of two techniques: the keyhole repair or the Sugarbaker repair. Both of these can be achieved robotically by an experienced surgeon.

The Sugarbaker repair involves reapproximation of the fascial defect, leaving room for the stoma contents, followed by mesh reinforcement over the entire fascial defect leaving a lateral mesh opening around the exiting loop of intestine. In the keyhole technique, the hernia defect is also closed, and mesh with a cutout keyhole is secured overlying the defect and around the stoma contents. The mesh in the keyhole repair can be placed intraperitoneal or in the retrorectus space. In both the Sugarbaker and keyhole types of repair, access to the space lateral to the stoma is difficult using an open approach. Use of the robotic platform can enhance visualization of this area and allow for adequate and safe fixation of the mesh in this difficult-to-access space. (See "Parastomal hernia".)

OUTCOMES — Robotic surgery may provide a minimally invasive option for ventral hernia cases that would typically require an open approach. However, it remains to be seen if robotics can provide clinical outcome benefits for patients. At this time, all studies have shown that robotic surgery requires more operative duration at a higher cost with unclear benefit. (See 'Surgical approaches' above.)

In a 2021 systematic review of three randomized trials and 22 comparative observational studies [29], robotic ventral hernia repair was associated with fewer blood transfusions, shorter hospital stay, and lower complication rates than open repair [29].

●One randomized trial comparing robotic with laparoscopic repair of 124 mostly <4 cm ventral hernias found no difference in 90 day postoperative hospital days, while robotic repair nearly doubled operating room time and significantly increased hospital cost [30]. Although robotic repair resulted in more enterotomies (3 versus 0 percent) and laparoscopic repair resulted in greater improvement in 30 day abdominal wall quality-of-life scores (15 versus 3 points out of 100), these differences were not statistically significant. At one-year follow-up, there was no significant difference in wound complication rate, hernia recurrence rate, readmission rate, or patient-reported outcomes [31]. No patients in the robotic arm and 9 percent of patients in the laparoscopic arm required reoperation.

●Another trial (PROVE-IT) that compared robotic with laparoscopic repair of 75 mostly <4 cm ventral hernias also found no difference in 30 day patient-reported outcomes [32]. Robotic repairs took a longer operative time and cost more. At one year, there was no difference in postoperative pain intensity [33]. Whereas hernia-specific quality-of-life survey scores increased by 12 points following robotic repairs compared with laparoscopic repairs, composite hernia recurrence (defined as radiographic, clinical, and self-reported recurrence) was 6 percent (2 of 33) for the laparoscopic cohort and 24 percent (9 of 38) for the robotic group. There was no difference in rates of reoperation.

●Another Brazilian trial compared robotic versus laparoscopic ventral hernia repairs in 37 patients who had undergone oncology surgery. There was no difference in hospital length of stay or complications [34], and the cost was higher for robotic repair ($14,700 versus $10,295) [35].

However, these trials did not address the repair of larger or more complex hernias or surgical techniques that negate the placement of intraperitoneal meshes. Additionally, larger trials are needed before wide adoption of robotic ventral hernia repair can be recommended.

In addition, surgeons also report that robotics may be beneficial to surgeon quality of life through improved ergonomics. Studies have demonstrated reductions in cognitive and physical stress with the use of robotic surgery compared with laparoscopy [36,37] as well as reduction in physical pain of the surgeon compared with other approaches. For surgeons suffering from musculoskeletal injuries from chronic use, such as neck or back pain, robotics can extend the career of a surgeon. However, robotics has also been associated with its own set of chronic use injuries, including carpel tunnel syndrome and neck pain [38].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ventral hernia" and "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

●Choice of surgical approaches – Ventral hernias are a common problem. When surgical repair is indicated, three options for surgical approach are available: open, laparoscopic, or robotic. (See 'Introduction' above.)

•Minimally invasive hernia repair has the advantage of potentially lowering the risk of surgical site infection. The decision to use an open versus a minimally invasive technique to repair a ventral hernia is discussed in detail separately. (See "Management of ventral hernias", section on 'Surgical management of ventral hernias'.)

•However, the role of robotic repair as a minimally invasive technique is unclear. Given the general lack of prospective data that distinguish the two minimally invasive techniques, the choice between laparoscopic and robotic repair should be made based upon surgeon expertise, availability of equipment, and surgeon/patient preference (shared decision making). (See 'Surgical approaches' above and 'Outcomes' above.)

•The absolute contraindication to robotic ventral hernia repair is patient intolerance of pneumoperitoneum. Relative contraindications include strangulated or acutely incarcerated hernia and patients with cirrhosis and portal hypertension. Additionally, patients with recurrent or incisional hernias or a history of other abdominal surgeries will likely require adhesiolysis at the time of hernia repair. This can be achieved robotically but will require additional operative time and careful port placement. Patients with large ventral hernias that also include soft tissue defects may benefit from a combined or hybrid open and minimally invasive approach. (See 'Contraindications' above.)

●Surgical techniques – Closure of the fascial defect and placement of mesh are key steps in ventral hernia repair. In a robotic ventral hernia repair, these can be achieved using one of four techniques: (1) defect closure and intraperitoneal onlay mesh (IPOM), (2) defect closure and preperitoneal/pretransversalis fascia placement of mesh, (3) placement of mesh in the retrorectus space, and (4) extension of the retrorectus dissection to a transversus abdominis release (TAR) in order to achieve defect closure. Selection of technique depends upon the size of the defect, location of the defect, type of hernia, and surgeon experience. (See 'Surgical techniques' above.)

●Off-midline ventral hernia repair – Off-midline ventral hernias, such as Spigelian, parastomal, and flank hernias, may also be repaired robotically but will require adjustments in patient positioning and port placement. (See 'Off-midline hernia repair' above.)