Minimally Invasive Repair of Recurrent Inguinal Hernia: Multi-Institutional Retrospective Comparison of Robotic Versus Laparoscopic Surgery

Abstract

Introduction:

Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia.

Methods:

All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach.

Results:

Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively).

Conclusions:

Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

Introduction

Laparoscopic repair of primary inguinal hernias was introduced in the beginning of the 1990s and has gained popularity throughout the years.^1–3 When compared with open surgery, laparoscopy is associated with faster recovery time, lower chronic pain, and comparable rates of recurrence.^3–6 Robotic repair of primary inguinal hernias was first described by Escobar Dominguez et al⁷ and several articles have already reported its outcomes in comparison with laparoscopy and open surgery.^8–10 However, the routine use of minimally invasive surgery for recurrent hernias is still debated.¹¹ Moreover, very little has been published on the use of the DaVinci for the treatment of inguinal recurrence.³ With this study we aimed to compare multi-institutional outcomes of robotic versus laparoscopic repair of recurrent inguinal hernias.

Methods

Ethical statement

All patients signed an informed consent , therefore no IRB approval was needed for the retrospective collection of their data.

This is a multi-institutional retrospectively designed study, based on prospectively maintained databases. All consecutive patients who had undergone minimally invasive (laparoscopic or robotic) repair of recurrent inguinal hernia between January 2014 and December 2021 in five different centers were included in this study.

Baseline characteristics retrieved from our databases were age, gender, body mass index (BMI), comorbidities, benign prostatic hyperplasia, smoking habit, Charlson comorbidity index, chronic anticoagulant therapy, and chronic antiplatelet therapy (CAPT). Perioperative data included mean operative time, bilateral inguinal hernia repair, length of stay, pain intensity. Pain was routinely assessed in each center using a visual analog scale (VAS). The VAS consisted of a 10 cm line, with two end points representing 0 (“no pain”) and 10 (“pain as bad as it could possibly be”).

Seroma, hematoma, surgical site infection (SSI), dysesthesia, and surgical site occurrence requiring procedural interventions (SSOPI) were considered as early (<30 days) complications. Chronic postoperative inguinal pain (CPIP) and recurrence were recorded as late (>30 days) complications.

The study was performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all participants included in the study.

Surgical technique

For laparoscopy, a three-port technique was performed as previously described, under general anesthesia using an umbilical trocar of 10-mm and two 5-mm trocars. The peritoneum was mobilized above the inguinal defect; sharp dissection was carried out to create the peritoneal flaps. The anatomical landmarks (Cooper's ligament, the iliopubic tract, and the inferior epigastric vessels) were identified, and the etiology and type of the recurrent hernia were determined. After the creation of adequate space, a nonabsorbable mesh was placed and fixed with absorbable tacks on the pubic bone, Cooper's ligament, and the aponeurotic arch. The peritoneum was closed with a running suture. The trocar sites were always closed.

For robotic surgery, The DaVinci (Intuitive™) was used to perform all the procedures with an umbilical trocar of 10-mm and two 8-mm trocars. Surgical procedure was similar to laparoscopy, but the mesh was fixed with interrupted stitches.

Postoperative care

Opioids were not allowed after the surgery to enhance recovery and paracetamol Pro re nata was the only used painkiller. Discharge was planned on after 12 hours or on day 1 in absence of complications or symptoms. Heavy lifting was not recommended for the first two postoperative weeks.

Statistical analysis

Variables were expressed as mean ± standard deviation or range and as percentages (%). For normally distributed parameters Student's t-test was performed. Chi-squared or Fisher's exact tests were used for categorical data; for statistical analysis, Microsoft Excel (Microsoft™) was used. A P value <.05 was set as significant.

Results

A total of 48 patients underwent inguinal hernia repair due to recurrent inguinal hernia after previous open surgery between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure (47.9%), whereas 25 (52.1%) were submitted to the laparoscopic intervention. Transabdominal preperitoneal (TAPP) technique was used in all patients.

Baseline characteristics of both groups are depicted in Table 1; in the robotic arm there were more patients on CAPT than in the laparoscopic one (17% versus 0%; P = .03, respectively).

Table 1.

Baseline Characteristics of Patients

	Robotic (n = 23)	Laparoscopic (n = 25)	P
Male, n (%)	22 (96%)	23 (92%)	.61
Age, mean (SD)	60.26 (14.3)	54.92 (14.4)	.20
BMI, mean, kg/m² (SD)	24.7 (2.8)	25.2 (3.7)	.59
Charlson score, mean (SD)	2.21 (1.8)	1.4 (1.3)	.07
BPH, n (%)^a	7 (32%)	5 (22%)	.45
Smoking, n (%)	3 (13%)	0 (0%)	.06
CACT, n (%)	3 (13%)	4 (16%)	.77
CAPT, n (%)	4 (17%)	0 (0%)	.03

Bold means P < 0.05.

The percentage was calculated to male patients.

BMI, body mass index; BPH, benign prostatic hyperplasia; CACT, chronic anticoagulant therapy; CAPT, chronic antiplatelet therapy; N, number of patients; SD, standard deviation.

Perioperative data of both groups are depicted in Table 2. Mean postoperative VAS score was significantly lower in the robotic than the laparoscopic arm (2.9 ± 0.5 versus 3.8 ± 1.2; P = .002, respectively). Mean operative time was slightly higher in the robotic group (96 minutes versus 79 minutes, respectively) without significance (P = .10). There were no conversions to open surgery recorded in both groups.

Table 2.

Perioperative Data of Patients

	Robotic (n = 23)	Laparoscopic (n = 25)	P
Bilateral repair, n (%)	7 (30%)	4 (16%)	.24
Mean operative time, minutes (SD)	96 (36)	79 (34)	.10
Mean VAS score (SD)	2.9 (0.5)	3.8 (1.2)	.002
Mean LOS, days (SD)	1.3 (0.6)	1.2 (0.5)	.49

Bold means P < 0.05.

LOS, length of stay; N, number of patients; SD, standard deviation; VAS, visual analog scale.

Postoperative rates of early and late complications are reported in Table 3. There was no clinically significant difference in the incidence of seroma, hematoma, SSI, dysesthesia, SSOPI, and recurrence. In the laparoscopic arm there was a significantly higher rate of patients suffering from CPIP (20% versus 0%; P = .02, respectively).

Table 3.

Clinical Outcomes of Patients

	Robotic (n = 23)	Laparoscopic (n = 25)	P
Seroma, n (%)	2 (8.7%)	1 (4%)	.51
Hematoma, n (%)	1 (4.3%)	1 (4%)	.95
SSI, n (%)	0 (0%)	1 (4%)	.34
Dysesthesia, n (%)	0 (0%)	0 (0%)	—
SSOPI, n (%)	0 (0%)	0 (0%)	—
Recurrence, n (%)	0 (0%)	0 (0%)	—
CPIP, n (%)	0 (0%)	5 (20%)	.02
Mesh explantation, n (%)	0 (0%)	0 (0%)	—
Overall complications	3 (13%)	8 (32%)	.17

CPIP, chronic postoperative inguinal pain; n, number of patients; SSI, surgical site infection; SSOPI, surgical site occurrences requiring procedural interventions.

Mean VAS score was significantly higher among those subjects who had CPIP than in the other patients (5.4 ± 1.33 versus 0.9 ± 0.7; P = .01). Overall mean follow-up time interval was 26.2 months (range 3–58) with no difference between groups.

Discussion

In the beginning of the 21st century, the rate of recurrence after open inguinal repair was reported to be 0.5%–15%.^12–17 This rate is continuously decreasing due to the more frequent use of prosthetic mesh.¹⁶ However, recurrence after abdominal wall hernia repair continues to be a major problem.^18,19

Risk factors for recurrence after open repair are well described^20–22 and can be classified as patient-related factors (older age, smoking, high BMI, and comorbidities) and technical factors. Some evidence seems to demonstrate that patient-related factors have a greater impact on recurrence.²¹

Despite the chosen approach, interventions for recurrent hernias are associated with an increased risk of testicular atrophy and nerve entrapment with subsequent chronic groin pain. Previously, guidelines for recurrence after open repair still recommended open preperitoneal approach to avoid scarred tissues. Currently, laparoscopy is strongly recommended for recurrent inguinal hernias.^3,12–24

Despite robotic repair gained popularity worldwide, when compared with the laparoscopic approach, no additional benefit has been proved; on the contrary robotic surgery may increase operative time and costs.^8–10,25

Our study has the advantage of specifically addressing these research questions in the selected group of patients with a recurrent inguinal hernia after open surgery. The minimally invasive (laparoscopic or robotic) approach showed acceptable perioperative outcomes and rates of postoperative complications. After a congruous follow-up of 26.2 months, no recurrence occurred in both groups. Qabbani et al²⁶ reported in a meta-analysis that there is no statistical significance when comparing the recurrence rate between robotic and laparoscopic surgery (1.4% versus 1.5%, P = .78). Mean operative time resulted slightly higher after robotic surgery, but without statistical or clinical significance.

Postoperative pain was also less severe after robotic-assisted surgery; as also demonstrated by a recent retrospective analysis,¹⁰ which found that median VAS score was 5, 2, and 0 in open, laparoscopic, and robotic procedure, respectively (P < .001).

Interestingly, also the incidence of chronic pain was lower in the robotic arm. Chronic pain was defined as pain occurring >3 months after inguinal hernia repair.²⁷ Lundström et al²⁸ have shown that persistent pain was reported in 15.2% of patients 1 year postoperatively; in addition, it was shown that the risk was least for endoscopic total extraperitoneal approach repair (adjusted odds ratio 0.84, 95% confidence interval 0.74–0.96) compared with open surgery. Bande et al²⁹ have reported that the incidence of pain was 13.6% at 4 months, 6.2% at 1 year, and 4.0% at 2 years.

A clinical randomized trial³⁰ reported that 5% of patients undergoing TAPP inguinal hernia repair still suffered from groin pain 5 years postoperatively. Several causative factors have been suggested, including female gender, young age, high intensity of preoperative pain, high intensity of early postoperative pain, history of other chronic pain, operation for a recurrent hernia, and open technique.³¹ Furthermore, in a review study it was noted that early high intensity pain after surgery is a risk factor for developing chronic pain.³² Interestingly, this finding was confirmed in our cohort, where mean postoperative VAS score in patients who developed chronic pain was significantly higher than in the other subjects.

Indeed, some authors have suggested that benefits of robotic inguinal hernia surgery include decreased postoperative pain related to suturing the mesh for fixation (instead of tack fixation in traditional laparoscopic repair)⁸; however, several reports did not show any difference in postoperative chronic pain when comparing the two approaches.²⁵

Strengths and limitations

Retrospective nature and small sample size are the main limitations of our study. However, to our knowledge, this is the first study comparing robotic and laparoscopic surgery for recurrent inguinal hernias after open approach. We suggest further large prospectively designed studies to clarify the early and long-term outcomes of minimally invasive repair.

Conclusions

Footnotes

Authors' Contributions

Conceptualization and writing by A.V.; data collection and calculation by A.A.A., R.P., L.F., G.F., R.d.G., and V.C.G.B.; supervision by P.P.B. and L.T.; revision of the final draft by M.M. and U.B.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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