Standard Laparoscopic Versus Robotic Retromuscular Ventral Hernia Repair

Jeremy A Warren, MD, William S Cobb, MD, Joseph A Ewing, MS, Alfredo M Carbonell, DO. Greenville Health System, University of South Carolina School of Medicine, Greenville

Laparoscopic ventral hernia repair (LVHR) is widely performed, with comparable recurrence rates to those reported with open repairs, but much lower incidence of surgical site infection (SSI).  However, there is potential for delayed complications associated with intraperitoneal placement of prosthetic mesh, particularly if a subsequent abdominal operation (SAO) is required.  Incidence of enterotomy or bowel resection during SAO with intraperitoneal mesh is as high as 20%.   Robotic instrumentation allows greater flexibility and dexterity to allow duplication of an open retromuscular hernia repair, which is our standard open technique, using a minimally invasive approach.  Robotic retromuscular ventral hernia repair (RRVHR) combines the lower wound morbidity associated with laparoscopy, with complete abdominal wall reconstruction (AWR) and extraperitoneal mesh placement previously only possible with open repair.

All LVHR and robotic RRVHR performed in our institution between June 2013 through May of 2015 and contained in the American Hernia Society Quality Collaborative (AHSQC) database were analyzed.  Continuous bivariate analyses were done with Students t-test.  Continuous non-parametric data were compared with Chi-squared test, or Fishers Exact for small sample sizes (n<5).  P-values <0.05 were considered statistically significant.

One-hundred three LVHR and 53 RRVHR were performed.  Patients were similar in race, ethnicity, comorbidities, wound classification, and American Society of Anesthesiology score, though the laparoscopic patients were older (60.2 v 52.9yrs; p=0.001). Mean hernia width and area were similar (6.9 v 6.5cm, p=0.508; 88cm2 v 82cm2, p=0.685).  Mesh area was larger with RRVHR (435cm2 v 339 cm2, p=0.014).  Fascial closure was achieved in 96.2% of robotic and 50.5% of laparoscopic cases (p<0.001).  Mesh was placed in an intraperitoneal position in 90.3% of laparoscopic repairs, and in a retromuscular or preperitoneal position in 96.2% of robotic repairs.  A myofascial release was performed in 64.2% of RRVHR.  Operative time was longer robotically (245 v 122min, p<0.001).  Seroma was more common after RRVHR (47.2% v 16.5%, p<0.001), but SSI was similar (3.8% v 1%, p=0.592).  Median length of stay was significantly shorter after RRVHR (1 v 2 days, p=0.004).  Mean direct hospital cost was similar (LVHR $13,943 v RRVHR $19,532; p=0.07).

Our technique for RRVHR obviates the need for intraperitoneal mesh and affords true abdominal wall reconstruction with myofascial releases to offset tension and allow midline fascial closure.  RRVHR is comparable in perioperative morbidity and cost to standard laparoscopic repair, but with significantly shorter length of stay despite a longer operative time and greater tissue dissection. 

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