Incisional Hernias after Robotic Assisted Surgery

Michael B Huck, MD, Myron Powell, MD, Stephen McNatt, MD, Carl Westcott, MD, Adolfo Fernandez, MD. Wake Forest Baptist Health

Proponents of robotic assisted surgery (RAS) argue that the rate of incisional hernia (IH) is lower than that of typical laparoscopic surgery. Use of smaller port-incision sites and less direct tissue trauma because of robotic instrument articulation have been used to support this assumption.  To date, there have been only a handful of case reports examining IH rates following RAS.  It is possible that IHs after RAS are underappreciated. To investigate this hypothesis, we examined our institutions experience with repairing IHs after RAS, and discuss these hernias in relation to reported information about laparoscopic IHs. 

We conducted a retrospective chart review of all patients that underwent robotic assisted surgery at our institution between September 2012 and April 2015.  These included surgeries within Urology, Gynecology, and General Surgery.  Primary outcome was incisional hernia requiring surgical repair within the Division of Minimally Invasive Surgery (MIS).  Secondary outcomes included patient characteristics at time of original surgery of BMI, Creatinine, hemoglobin A1c, albumin and smoking status as well as the site of hernia, and type of closure required.  Other secondary outcomes included length of stay of original surgery and at time or repair.

We identified 1,269 patients who underwent abdominal robotic assisted surgery at our institution between September 2012 and April 2015.  Of these patients, 20 patients developed 21 symptomatic incisional hernias resulting in an incidence of 1.65%.  Of the 21 IHs repaired, 14 occurred at extraction sites, and 7 occurred at port sites.  Of the 7 IHs that occurred at port sites, 4/7 occurred at 8mm port sites, and 3/7 occurred at 12 mm port sites.  Fascia of the 12 mm port sites, and extraction sites were closed, but not the 8mm sites.  The fascia of extraction sites were closed during original surgery. Fascial defect at time of repair ranged from 1 cm to 5 cm, with average size 2.1 cm in greatest dimension.  1/7 where repaired in open technique, 6/7 were repaired laparoscopically. 

Our results show that IHs are possible after RAS, even at sites away from the specimen extraction site or camera port.  Our incidence for IHs are in line with previously published data and infer no protective effect for IHs inherent to robotic surgery.  Our study is limited with respect to small numbers, and that only patients who underwent repair within our Department of MIS are included.  RAS is not safer than laparoscopic surgery in relation to post-operative IH formation.