Robotic Trans-abdominal Pre-peritoneal Inguinal Hernia Repair: Is there a benefit?

Salvatore Docimo, Jr., DO, Hayk Stepanyan, Josh S Winder, Randy S Haluck, Jerome R Lyn-Sue. Penn State Hershey Medical Center

INTRODUCTION:  Laparoscopic inguinal herniorrhaphy can be performed utilizing trans abdominal pre peritoneal approach (TAPP) and the totally extra peritoneal approach (TEP). These approaches offer similar operative times, post-operative pain, return to work and hernia recurrence1.  The TAPP herniorrhaphy may also performed with robotic assistance. We describe our initial experience utilizing robotic (Da Vinci Surgical System Sunnyvale, CA) TAPP inguinal herniorrhaphy versus laparoscopic TEP (LTEP) inguinal hernia repair.

METHODS:  A retrospective review from June 2014 to June 2015 was performed.  The records for all patients who underwent robotic TAPP (RTAPP) and LTEP at Penn State Hershey Medical Center were reviewed. Operative time, complication rate, and length of stay were determined. The average cost of each procedure was also compared.

RESULTS: Forty patients were included in the study, 20 patients in both the RTAPP and 20 in the LTEP group. The mean age in the robotic group (RG) was 56.6 years and the laparoscopic group (LG) was 55.9 years (p=0.5899). The mean BMI in the RG was 27.4 kg/m2 and mean BMI for the LG was 26.5 kg/m2 (p=0.50894).  The average operative time for the RG was 134 minutes compared to 64.3 minutes for the LG (p=<0.00001). There was no statistical difference in average operative time between the first 10 robotic patients (111 minutes) and second 10 robotic patient (134 minutes) (p = 0.064621). The mean length of stay for the RTAPP was 12.9 hours and 9.2 for the LTEP (p=0.0762). There were no minor or major complications in either of the groups.  The average cost per case for RTAPP was $2,364 and $1,503 for LTEP. There were 2 patients in the RTAPP that would not have been considered for TEP repair. One patient with a large incarcerated inguinal hernia and another patient with sliding hernia with the urinary bladder in the inguino-scrotal region.

CONCLUSIONS:  The improved dexterity and increased degrees of freedom that the Da Vinci robotic system offers (Intuitive Surgical Sunnyvale, CA) did not decrease operative times in our early experience.  Although both groups offered similar outcomes, such as similar length of stay and complication rates, the increased operative time and cost makes laparoscopic TEP hernia repair the ideal operative method at this time. However, robotic hernia repair will likely play a role in difficult cases.  Further studies regarding focusing on postoperative pain and recurrence rate in these complex difficult cases are required.  A tailored approach may be needed overall.

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