Ventral hernia repair is one of the most common operations performed in the US. Despite advances in minimally invasive approaches, a large majority is still performed by open incisions. New advances in laparoscopy and robotic surgery are starting to demonstrate improved outcomes over the traditional techniques.
What is a hernia?
A hernia is a weakness in the abdominal wall through which organs can protrude. It usually presents as a painless bulge, but can develop symptoms including pain, and rarely obstruction. One quarter of all individuals are either born or will develop a ventral hernia in their lifetimes and over $3.4 billion is spent annually repairing them. Incisional hernias can occur in 10-23% of patients with previous surgery.
The natural history of hernias is that once they form, the weakness is progressive and will grow over time. Although the rate of growth is not predictable, infection, obesity, malnutrition, immunosuppressive medication, and tobacco use are some of the common risk factors for developing a hernia and contributing to their growth. Studies comparing a watchful waiting approach vs. early repair for asymptomatic hernias demonstrate that up to 19% of patients will develop symptoms over 5 years that will require operative intervention and 4% will need emergent surgery. By then, usually the hernia has progressed in size, making repair more difficult. Also, since patients are now older, new or worsening comorbidities may complicate their perioperative recovery. As a result, most hernia surgeons today tend to recommend that elective repair at the time the hernia is identified should be offered to the patient.
Approximately 120,000 hernia operations occur annually in the US. According to the American college of surgeons, open repair still constitutes 83% of all ventral hernia operations. However, there is no consensus among surgeons regarding the best open approach and continue to debate the merits of one mesh over another or the placement of on-lay, retrorectus, or sublay mesh. Meanwhile, laparoscopic IPOM repair constitutes about 20% of ventral hernia operations and has become more prevalent over the past 10 years.
Many studies have compared open to laparoscopic repair and identified consistent advantages for the laparoscopic technique including shorter length of stay, less post operative pain, less preoperative complications, and earlier return to work. In addition, some data suggests laparoscopy has particular appeal in obese patients. Newer data now even suggests less cost associated with laparoscopic repair.
Coated intra-abdominal mesh has an anti-adhesive barrier on the bowel facing side to minimize adhesions. This type of mesh allows laparoscopic mesh placement below the fascia, meaning it is re-enforced by pressure from abdominal content. In contrast, open mesh repair is usually placed above the fascia, where intra-abdominal pressure can exert tension on the repair.
As hernias get larger, so does the length of the open repair incision. This can increase the risk of postoperative wound healing complications. Laparoscopic incisions are the same regardless of the hernia size. Robotic ports are placed laterally where the risk of port site hernias is lowest.
New suture materials with barbed edges give self-retaining sutures good grip on tissue and tight closure. In addition, they can distribute the tension along the entire length of the suture, while conventional sutures focus tension to the edges and on the knot. These novel sutures coupled with robotic wristed instruments greatly enhance the surgeon’s ability to suture upside down, thus enabling closure of the hernia defect, and securing mesh to the abdominal wall.
Over the past five years, robot-assisted laparoscopic surgery has had tremendous growth. Robotic surgery inherently has some advantages over conventional laparoscopy including wristed instruments, 3-D vision, and the easier suturing. Moreover, robotics has specific advantages over conventional laparoscopy in hernia operations. These include placing the rectus muscles back in a correct anatomical position by closure of the hernia defect, collapsing the hernia sack to reduce seromas, and the ability to suture mesh to the abdominal wall instead of using painful tacking devices and trans-facial sutures.
Distribution of robotic hernia repair by region. The predominant number of robotic hernia operations in 2012 were concentrated in the eastern US. Since that time, that trend has continued. While adoption in the western US has also increased, it has lagged that of the rest of the country untill only recently.
National trends in robotic adoption for combined ventral and inguinal hernia. As more hernia surgeons recognize the benefits of robotic surgery (dV), the numbers of open and conventional laparoscopic repairs are decreasing.
The initial literature regarding robotic ventral hernia repair was mixed. While demonstrating comparable efficacy, it was associated with increased costs. However, as the field has matured, the latest publications now suggest improved outcomes over open repair in recurrence rates, shorter hospitalizations, less perioperative complications, and lower costs.
Studies questioning the benefit of robotic surgery based on higher cost may be confounded by the learning curve associated with mastering new techniques. Studies investigating the costs, quality, and open conversion rates for robotic surgeons show improvement in these metrics as surgeons become more proficient.
A recent publication from the American Hernia Society Quality Collaborative compared laparoscopic and robotic repair by experienced hernia surgeons. The results found decreased length of stay, surgical site infection and other short-term prioperative complications with the robotic repair. While not directly measuring cost, their data also seems to suggest that despite longer operative time, shorter length of stay could result in parity if not lower cost with robotic repair, but future studies are needed to evaluate these trends.
General surgery is the fasted growing segment of robotic operations in the US today. This is especially true in urban markets, particularly, the Northeast. As this wave has spread, California had lagged in adoption. That has started to shift as surgeons, referring physicians, patients, and hospital systems become aware of the benefits of robotic ventral hernia repair.
daVinci Xi robot with rotating boom design allows multi-quadrant surgery, superior 3D imaging compared to laparoscopy and wristed instrumentation.