Ventral and incisional hernias are common with over 350,000 procedures performed annually in the United States [1–3]. Robotic-assisted minimally invasive surgery (MIS) for abdominal wall reconstruction has been facing a fast adoption worldwide growing at an exponential rate [4–6]. The laparoscopic repair faces challenges such as inability to properly close the fascial defect especially in large ventral hernias, limited dexterity to perform complex component separation techniques and limited options for mesh fixation [7].

The robotic platform offers clear advantages over laparoscopy. The three-dimensional view of the surgical field and articulating instruments with increased degrees of freedom allow surgeons to perform more precise movements and, therefore, to perform more challenging minimally invasive repairs [8]. Furthermore, the increased access to the robotic platform increased the rate of repairs performed with MIS [9]. However, the clinical efficacy and advantages of robotic hernia repair over laparoscopic surgery is still debatable with similar postoperative outcomes [10].

Despite the natural interpretation that a more articulating system would provide more dexterity, it is still important to better understand how the robotic platform impacted ventral hernia repairs through the years. The aim of this study is to compare Robotic ventral hernia repair (VHR) to the laparoscopic approach through the analysis of the complexity of hernia repairs in the last 5 years in the United States utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database.

ACHQC database identified 11,096 patients with midline hernias who underwent VHR with mesh from 2018 to 2023. The Laparoscopic (LAP) group with patients had 2,063 patients, and the robotic (ROBO) group had 9,033 patients. There was no difference in sex, age, BMI, DM, smoking status and COPD between groups. The baseline characteristics are listed in Table 1.

Median hernia width was 4 cm (IQR 2–6) in the ROBO group and 3 cm (IQR 2–5) in the LAP group (p < 0.001). Median hernia length higher in the ROBO group 5 cm (IQR 2.5–10) versus 3 cm (IQR 2–5) in the LAP group. Incisional hernia was higher in the ROBO group 5,259 (58%) versus 1,099 (53%) in the LAP group (p < 0.001). Recurrent hernia was more common in the ROBO group when compared with the LAP group (p < 0.001) (Table 2) Both groups had more permanent synthetic mesh. Retromuscular repair was higher in the ROBO group, 3,201 (37.6%) versus 68 (4.2%) in the LAP group (p < 0.001). The intraperitoneal repair was higher in the LAP group 1,363 (83%) versus 2,925 (34%) in the ROBO group (p < 0.001). Transversus Abdominis Release (TAR) was higher in the ROBO group 1,314 (14.5%) versus 5 (0.2%) in the LAP group (p < 0.001). Fascial closure was higher in the ROBO group (8,649; 96.5% versus 1,359; 67.3% in the LAP group p < 0.001). Regarding mesh fixation, regular suture was higher in the ROBO group 92% versus 61% in the LAP group (p < 0.001). Tacks (p < 0.001) was higher in the LAP group (Table 2) The RobO group had more patients with an operative time of 240+ minutes when compared with the LAP group (p < 0.001). There was no difference in intraoperative complications between the groups (Table 2). Median LOS was similar in both groups with patients going home in the immediate postoperative time, however, laparoscopic approach was associated with a higher IQR and patients going home postop day 1 or 2 (p < 0.002).

There was no difference in 30-days readmission rates, recurrence, reoperation, overall postoperative complications, 30-day SSI, SSO, seroma and SSOPI between the groups (Table 3).

Our study demonstrated that the robotic-assisted surgery had higher rates of fascial closure, myofascial release, and mesh fixation using suture when compared to the laparoscopic group. Furthermore, the robotic group had higher median hernia width and length than the laparoscopic group. There was no difference in 30-day SSI, SSO, seroma formation and SSOPI between the groups. We aimed to compare the last 5 years of laparoscopic ventral hernia repair with the robotic approach. Laparoscopic surgery is well established with surgeons already with extensive experience while the robotic assisted technique still is new for a considerable number of surgeons in the United States with access to the robotic platforms more recently.

A recent meta-analysis comparing robotic and laparoscopic ventral hernia repair with 5 studies and 3,732 patients showed that the robotic approach was associated with longer operative time and no differences in SSO and recurrence [10]. This is in accordance with our study. We found that the robotic approach had more cases with more than 240 min. Since most laparoscopic cases were intraperitoneal mesh repair with the use of tacks and lower rates of fascial closure, it makes sense that these cases were less challenging to surgeons. Other studies have also demonstrated increased OT with the robotic platform [11, 12].

Howard et al. analyzing trends in ventral hernia repair in the United States from 2007 to 2015 observed an increase in MIS techniques, component separation and mesh use [1]. Other studies also observed the increased adoption of these techniques [13, 14]. Madion et al. found a 2-fold increase in MIS techniques for ventral hernia repair with stable wound morbidity in all MIS modalities and decreased wound morbidity when compared to open surgery [13]. A review of the Michigan Surgical Quality Collaborative showed an increased proportion of robotic ventral hernia repair up to 22.5% between 2012 and 2018 [4].

The Robotic approach has become popular among surgeons due to possibility to perform more complex repairs in a minimally invasive fashion with decreased postoperative wound morbidity. Some techniques that were previously only able to be mainly performed by open technique such as retromuscular mesh repair with transversus abdominis release can now be performed with the robotic platform and with similar wound morbidity and lower length of stay [15–18]. Henriksen et al (2024) performed a retrospective propensity score matching study comparing robotic RM (retromuscular) repair with laparoscopic IPOM (intraperitoneal onlay mesh) repair with 1,136 patients from the Danish Hernia Database. The authors found that for primary ventral hernias IPOM repair had a higher group of smaller mean vertical defect size when compared to the robotic RM repair. Furthermore, authors found that the laparoscopic IPOM was associated with longer mean LOS and higher rates of readmissions within 90 days [19]. This is in accordance to our study where median LOS was the same for both groups with laparoscopic group having more outliers in the postoperative day 1 or 2 when compared to the robotic approach.

The significance of haptic feedback in robotic surgery remains a topic of debate. Early 2000s research on robotic systems suggested that the absence of haptic feedback might contribute to unintentional tissue injury [19, 20]. However, skilled surgeons can compensate by relying on visual cues, such as tissue deformation, to assess force [21, 22]. Meccariello et al. demonstrated that experienced surgeons more accurately identified the thickness of custom-made membranes without haptic feedback compared to junior surgeons [23]. To date, no studies have examined the impact of missing haptic feedback on tissue trauma in abdominal wall surgery, and our findings do not indicate any difference in outcomes [24].

The Robotic approach was associated with more technically challenging ventral hernia repairs with low complication rates over time. However, no differences in postoperative complications were found between the groups.