Multi-center analysis of robotic inguinal hernia outcomes across New York State

Monica Cramer, Jie Yang, PhD, Maria Altieri, MD, Aurora Pryor, Yaqi Xue, Mark Talamini, Dana A Telem, MD. Stony Brook Medicine

Background: Utilization of robotics for inguinal hernia repair is steadily increasing. A major criticism surrounding this technology centers on its adoption outpacing supportive data. Additionally, a uniform benchmark of proficiency is not established with volume serving as a questionable surrogate marker. This study represents one of the first to date assessing outcomes following robotic inguinal hernia as well as the impact of hospital and surgeon volume on outcomes.

Methods: Following Institutional Review Board and New York State approval, 19,677 patients who underwent laparoscopic and robotic inguinal hernia (RIH) repair from 2010-2013 were identified. Patients were identified using the New York Statewide Planning and Research Cooperative System (SPARCS) longitudinal administrative database. Chi-squared tests compared unadjusted marginal differences for categorical variables and Welch’s ANOVA and non-parametric tests compared unadjusted marginal differences for continuous variables. Propensity score (PS) analysis was used to estimate the adjusted marginal differences.  P-values<0.05 were considered significant.

Results: In total, 284 patients underwent RIH at 37 institutions (range 1–51 operations). Univariate analysis demonstrated RIH repair had significantly higher rates of perioperative complication (12.7% vs. 0.9%, p<0.0001), 30-day readmission (6.3% vs. 1.3%, p<0.0001), 30-day emergency department (ED) utilization (11.3% and 5.3%, p<0.0001) and longer length of stay (LOS) (2.3 vs. 0.2 days, p<0.0001) in relation to laparoscopy. The majority (90%) of robotic complications were minor and related to digestive issues. A significant discrepancy in population characteristics and comorbidity profile was demonstrated prompting PS analysis. PS analysis demonstrated no significant difference in any clinical outcome metric between procedures: complication (p=1), readmission (p=0.7), ED utilization (p=0.13), and LOS (p=0.31).

Patient outcomes were also compared among cumulative RIH hospital volume classifications: (≤10, 11-20 and ≥21) and surgeon volume classifications (≤5, 6-10 and ≥11). No significant difference in any outcome metric was demonstrated by volume. Hospital volume: complication (9.5% vs. 12.7% vs. 14.9%, p=0.47), readmission (6.3% vs. 5.5% vs. 6.7%, p=0.58), and ED utilization (11.6% vs. 10.9% vs. 11.2%, p=1.0), respectively. Surgeon volume: complication (7.6% vs. 11.4% vs. 17.0%, p=0.08), readmission (8.6% vs. 4.6% vs. 5.2%, p=0.58), and ED utilization (13.3% vs. 11.4% vs. 9.6%, p=0.67).

Conclusion: In relation to laparoscopy, robotic surgery did not result in significant outcome differences in terms of complications and perioperative health resource utilization. Hospital and surgeon volume also did not impact patient outcome in this study.

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