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Original article
Robotic inguinal hernia repair: Is it a new era in the management of
inguinal hernias?
Eli Kakiashvili
a
,
b
,
*
, Maxim Bez
c
, Ibrahim Abu Shakra
a
, Samer Ganam
a
, Amitai Bickel
a
,
b
,
Fahed Merei
a
, Assi Drobot
a
, Grigori Bogouslavski
a
, Walid Kassis
a
, Kamal Khatib
a
,
Mahran Badran
a
, Yoram Kluger
d
, Ronit Almog
e
a
Department of Surgery A, Galilee Medical Center, Nahariya, Israel
b
Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
c
Medical Corps, Israel Defense Forces, Ramat Gan, Israel
d
Department of General Surgery, Rambam Medical Center, Haifa, Israel
e
Director of Epidemiology Unit, Rambam Medical Center, Haifa, Israel
article info
Article history:
Received 18 November 2019
Received in revised form
9 March 2020
Accepted 23 March 2020
Available online xxx
abstract
Objective: We compared outcomes of elective inguinal hernia repair performed at one institution by
three approaches: robotic-assistance, laparoscopic, and open.
Methods: Characteristics of the patients, the hernia and the procedures performed during 2014e2016
were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries
were robotic-assisted, 16 laparoscopic and 97 open repairs.
Results: Distributions of age, sex and BMI did not differ between the groups. Bilateral repair was more
common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p <0.001). Direct
hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups
(p <0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times
were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p <0.001).
Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic
procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for
2e3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this dif-
ference was not statistically significant. The median maximal postoperative pain according to a 0-10-
point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respec-
tively (p <0.001).
Conclusions: This report demonstrated the safety and feasibility of robotic-assisted inguinal hernia
repair.
©2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
1. Introduction
Inguinal hernias account for 75% of all abdominal wall hernias;
the lifetime risk is 27% in men and 3% in women. Repair of these
hernias is one of the most common surgical procedures in the
world.
1
In the United States, approximately 800,000 inguinal hernia
repairs are performed annually.
2
Historically, hernias have been documented dating back to the
ancient Greco-Roman period. Since then, treatment of groin hernias
has evolved through 6 major eras.
3e5
The first era takes us to the
Egyptian papyrus Ebers period, during which the hernia was
described as a “swelling that comes out when one coughs.”The
second era began in the “Renaissance”, during which the knowl-
edge of surgical anatomy increased substantially. The treatment,
however, was limited to life threatening disease such as incarcer-
ated hernias. In the third era, anesthesia and aseptic technique
advanced hernia surgery. This was evidenced by significantly lower
complications, but recurrence rates remained at 100% at four years.
The 19th to mid-20th century gave rise to the fourth era, during
*Corresponding author. Department of Surgery A, Galilee Medical Center,
Nahariya, Israel.
E-mail addresses: elik@gmc.gov.il (E. Kakiashvili), ibra89him.abushakra@gmail.
com (I. Abu Shakra).
Contents lists available at ScienceDirect
Asian Journal of Surgery
journal homepage: www.e-asianjournalsurgery.com
https://doi.org/10.1016/j.asjsur.2020.03.015
1015-9584/©2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Asian Journal of Surgery xxx (xxxx) xxx
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
which repair was performed under tension with the reconstruction
of the posterior wall of the inguinal canal, pioneered by Bassini and
Shouldice. The fifth era marked repair without tension with the use
of prosthetic materials pioneered by Lichtenstein. Over 1000 cases
of this type of repair were published and demonstrated no re-
currences at 5 years. The sixth era started in 1979 when P. Fletcher
introduced the laparoscopic technique for the management of
inguinal hernia. In the 1990s, the two main techniques for laparo-
scopic hernia repair were developed and refined: the trans-
abdominal pre-peritoneal (TAPP) approach and the totally extra-
peritoneal (TEP) approach. Neither technique has been demon-
strated as superior. Both TAPP and TEP have similar operative times,
post-operative pain, the timing of return to work and
recurrences.
8,9
Open, mesh-based, tension-free repair remains the standard
technique for laparoscopic hernia repair. Performed by adequately
trained surgeons, the results are excellent, and comparable to those
of open repair.
6,7
Laparoscopic inguinal hernia repair has certain
advantages over open repair including reduced postoperative pain,
a diminished requirement for narcotics, and earlier return to work
and normal activities.
8e12
Disadvantages of laparoscopic repair
include increased costs, longer operating room time, a steeper
learning curve, and higher recurrence and complication rates early
in a surgeon's experience. Importantly, a prolonged learning curve
has limited more generalized application of a minimally invasive
approach in the management of groin hernias.
Robotic-assisted surgery is well established as a technique that
provides improved three-dimensional visualization and enhanced
dexterity with articulating instrumentation. However, its applica-
tion and true benefit in general surgery, and in groin hernia surgery
in particular is still under investigation. Relative contraindications
to robotic-assisted surgeries include: previous laparoscopic repair,
ascites, peritoneal dialysis and large inguinoscrotal hernias.
13
Other
strong contraindications for minimally invasive inguinal hernia
repair include multiple previous abdominal surgeries, the inability
to tolerate pneumoperitoneum and a grossly contaminated
abdominal cavity that would preclude the use of a mesh.
In this study we present the initial experience of robotic inguinal
hernia repair performed by one surgeon at a single institution. The
aim is to demonstrate the feasibility and safety of the robotic
approach. All the robotic procedures were compared to traditional
open and laparoscopic inguinal hernia repairs performed in the
same institution during the same period by different surgeons. The
goal of the comparison was to determine whether robotic assis-
tance confers a benefit and superiority over the other two ap-
proaches, and may thus be expected to dominate minimally
invasive inguinal hernia repair in the future.
2. Methods
2.1. Patient selection
We reviewed the electronic medical files of all the patients who
underwent elective surgery due to an inguinal hernia at Rambam
Health Care Campus, Israel, during the period 2014 to 2016 by a
single surgeon with over 15 years of experience in open and lapa-
roscopic hernia repair and approximately 200 major oncologic
surgeries using robotic assistance. Inclusion criteria were: age18 ,
a uni/bilateral inguinal hernia, a direct/indirect hernia, and first or
recurrent inguinal hernias. For each patient we collected informa-
tion on age, sex, BMI, hernia characteristics: type (indirect/direct/
both), laterality (unilateral/bilateral), inguinoscrotal (yes/no),
recurrent (yes/no). Operative procedure details included: type
(open/laparoscopic/robotic), TAPP/TEP, and the operation time. The
latter was defined as the time between start of the surgery (first
incision) and the finish of surgery (closure of the skin). Post-
operative discharge days of hospitalization (POD) were calculated
as the difference between the operation date and the discharge
date. POD was analyzed as a dichotomous variable: 1 day and >1
day, as the vast majority of patients were hospitalized for 1 day.
Postoperative pain was assessed by 2 measures: maximal post-
operative Visual Analogue Scale (VAS) measurement (on a scale of
0e10, with 10 representing the maximum pain) and the mean
number of times that analgesic drugs were dispensed to patients
during the 24-h postoperative period. The drugs that were
considered were opioid and non-opioid analgesics, including ATC
third level code N02A and N02B. The most common drugs that
were used were dipyrone, paracetamol, oxycodone and tramadol.
2.2. The robotic-assisted surgical technique
All robotic cases were operated using the da Vinci Si surgical
platform. We employed three robotic arms: one for the camera and
two for robotic instruments. The camera port (12 mm) is placed at
the supra-umbilical area. We used a zero-degree camera, which
enables full and adequate visualization. Two other robotic ports
(8 mm) are localized 9 cm from the umbilicus (each site) at the level
of the umbilicus. We usually use one assistant port (10 mm) localized
in the right lower quadrant, which allows mesh and needle place-
ment into the abdominal cavity (Fig. 1). Our patient's position of
choice during operation is supine lithotomy with complete Trende-
lenburg. The robot is docked between the patient's legs (Fig. 2).
We prefer performing robotic inguinal hernia repair through the
TAPP approach. The relevant inguinal anatomy in this approach is
differentthan in the open or TEP approach. The importantanatomical
landmarksin the peritoneal cavityare: the medial umbilical ligament,
the internal inguinal ring and the inferior epigastric vessels.
Fig. 1. Placement of ports during robotic assisted inguinal hernia repair.
port placement: C- camera port, R1 and R2-robotic ports, A - assistant port.
E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx2
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
A curvilinearperitoneal incision is performed with the robotic hot
shears between the anterior superior iliac spine and the medial um-
bilicalligament, abovethe internal inguinalring. An incisionis created
that will enablesdissection of Cooper'sligament and a peritonealflap,
and that accommodates the appropriate sized meshcomfortably. The
pre-peritoneal fat can be dissected bluntly and with modest use of
cautery, with care not to injure the inferior epigastric vessels. Visu-
alizationof these vessels is mandatory todetermine the type of hernia
(medial to the vessels is a direct hernia, and lateral to the vessels is an
indirecthernia). Ideally, the peritoneal flap shouldfitsnugtothemesh
without “mesh rolling.”This also prevents mesh migration, which is
critical in the early period after repair.
Dissecting Cooper's ligament, just lateral to the symphysis pu-
bis, immediately after creating the peritoneal flap, usually facili-
tates recognition of the pre-peritoneal anatomy. Our practice is to
dissect and identify Cooper's ligament first, before addressing the
rest of the dissection. Having Cooper's ligament in view serves as a
useful landmark, especially when the hernia sac is large and ob-
scures the field of dissection. Once Cooper's ligament is identified, a
lateral dissection of the pre-peritoneal space is required, thus
leaving the hernia sac dissection until the end, and facilitating
identification of the spermatic cord, the vas deferens and the tri-
angle of doom (Fig. 3).
The hernia sac must be detached completely from the spermatic
cord to avoid seroma formation and hernia recurrence. In cases of
very large hernia sacs, such as inguinoscrotal hernias, in which
dissection may become challenging, the sac may be transected and
left in place. Caution should be taken to close the peritoneal defect
once the inguinal repair is completed.
According to the guidelines of the International Endohernia
Society, the recommended mesh size is 10 15 cm.
14
In all robotic
cases we used the 15/10 cm laparoscopic Progrip self-fixating mesh
(Medtronic, Minneapolis, MN), which comprises anatomical
monofilament polyester with absorbable polylactic acid grips and
absorbable collagen film. The important sites for fixating the mesh
are: Cooper's ligament, the rectus abdominis muscle (medial to the
inferior epigastric vessels) and the transverse abdominis fascia,
slightly lateral and above the internal inguinal ring.
During bilateral inguinal hernia repair, we create two distinct
peritoneal incisions that form two peritoneal flaps on either side.
Fig. 2. Patient in the lithotomy position and robot docking.
Fig. 3. The right inguinal region in robotic-assisted inguinal hernia repair.
1) supravesical fossa, 2) Cooper's ligament, 3) inferior epigastric vessels, 4) transverse
arch, 5) vas deferens, 6) cord elements with gonadal vessels, and 7) peritoneal flap, the
triangle of doom (solid lines), the triangle of pain (dashed lines).
E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx 3
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
This has been shown to be more than adequate for the dissection.
At the end of the hernia repair, the peritoneum is closed with
barbed sutures (V-Loc 3e0, Medtronic, Minneapolis, MN). This re-
duces operating time significantly and may also cause less post-
operative pain than surgical tackers.
2.3. Laparoscopic and open surgical technique
For TAPP repair, a supra-umbilical incision is made to access the
peritoneal cavity and a 10e12 mm trocar placed, and two 5-mm
ports either in the midline below the umbilicus or in the mid-
clavicular line bilaterally. The hernia is visualized by a 30 degree-
angle laparoscope. The inferior epigastric vessels, the spermatic
vessels, and the vas deferens should be identified, the peritoneum
is incised several centimeters above the myopectineal orifice, from
the edge of the medial umbilical ligament laterally toward the
anterior superior iliac spine. The peritoneum is dissected off the
transversus abdominus and transversalis fascia until the pubis,
Cooper's ligament, and iliopubic tract are identified. An indirect
hernia sac is usually found on the anterolateral side of the cord. The
vas deferens and spermatic vessels are isolated and dissected free
from the surrounding tissues circumferentially, creating a window
inferiorly, to allow for passage of the mesh. At the end of the hernia
repair, the peritoneum is closed by absorbable barbed suture (V-Loc
3e0, Medtronic, Minneapolis, MN).
For Laparoscopic TEP, the port placement is similar to that for a
TAPP repair, except all ports are placed in the preperitoneal space.
The first 10e12 mm port is placed using an open technique. A sub-
umbilical skin incision is made and then advanced slightly off the
midline, in front of the anterior rectus sheath. The anterior sheath is
opened transversely and the rectus muscle is swept laterally and
retracted anteriorly. The posterior rectus sheath is seen and left
intact. The 10-mm balloon-tip port is then inserted bluntly into the
preperitoneal space and inflated. A 10-mm, 30-angle laparoscope is
placed and used to bluntly dissect the tissue in the preperitoneal
space. The preperitoneal space is dissected laterally to the anterior
superior iliac spine in order to place the 5-mm ports. The inferior
epigastric vessels, the pubic bone, and Cooper's ligament are
identified. Cooper's ligament is exposed, a direct hernia, if present,
will generally be reduced and a pseudosac may be found. Indirect
hernia sacs are managed the same as for TAPP repairs. Cord lipomas
are usually found laterally along the spermatic vessels and should
be reduced. Mesh placed is the same as for a TAPP procedure.
The Bassini repair is performed by suturing the transversus
abdominis and internal oblique musculoaponeurotic arches or
conjoined tendon (when present) to the inguinal ligament.
2.4. Statistical analysis
The chi square test and Fisher's exact test were performed to
determine significant differences in categorical variables between
the 3 hernia repair procedures: open, laparoscopic and robotic.
ANOVA and the non-parametric KruskaleWallis tests were used to
compare continuous variables according to data distribution. Sta-
tistical significance was defined as a two-tailed test with P <0.05.
All analyses were performed using SPSS software, version 21.
3. Results
Overall, 137 patients who underwent elective inguinal hernia
repair during the study period were included in the cohort. Of
them, 97 underwent open repair, 24 robotic repair and 16 laparo-
scopic repair. Table 1 compares demographic and clinical charac-
teristics and compares between the three procedure groups. No
significant differences were found in age, sex or BMI between the
groups. Bilateral repair was more common in the robotic (70.8%)
than the laparoscopic (50.0%) and open groups (12.4%) (p <0.001).
Direct hernias were more common in the open (45.4%) than the
robotic (20.8%) and laparoscopic (12.5%) groups (p <0.001). Only 3
hernias were inguinoscrotal hernia, all of them in the robotic group.
Nine (56.3%) of the 16 laparoscopic repairs were performed ac-
cording to the TAPP method.
Table 2 presents the operative and postoperative outcomes by
operation type. Operation time significantly varied between the
three operation methods. Median operation times were 44.0, 79.0
and 92.5 min for the open, laparoscopic and robotic methods,
respectively (p <0.001). The operative time did not differ signifi-
cantly between the laparoscopic and robotic repair techniques.
Among the bilateral repairs, the relative differences in median
operative times remained: 67.5, 89.0 and 105.0 min, respectively,
for the three procedures. Among the unilateral repairs, the median
operative times were the same for the robotic and laparoscopic
procedures, 73 min, and less for the open procedures, 40 min. The
proportion of patients hospitalized for 2e3 days was higher for
open repair (13.4% vs. 6.2% and 0% forlaparoscopic and robotic), but
this difference was not statistically significant. The median of
maximal postoperative pain according to the VAS was 5, 2 and 0 for
open, laparoscopic and robotic procedures, respectively (p <0.001).
The median number of analgesics during the first 24 h post-
operative was significantly higher following open compared to
laparoscopic and robotic procedures: 3.0, 1.5, 1.5, respectively
(p <0.001).
4. Discussion
The results of the present study indicate that robotic hernia
repair is feasible for all types of hernias (bilateral, recurrent, direct
and indirect, and inguinoscrotal) and for patients with various
characteristics. Postoperative discharge days and analgesic con-
sumption were similar following robot-assisted and laparoscopic
repair. For these measures, robotic and laparoscopic approaches
fared better than open procedures. This corroborates previous
knowledge of differences between open and laparoscopic repair.
More than 75% of the patients who underwent robotic repair re-
ported VAS 0 in all their measurements and this was significantly
different from the open and laparoscopic groups. However,
reporting bias should be considered, since patients and staff were
not blinded regarding the procedure type or the surgeon's experi-
ence. Operation time was similar between laparoscopic and robotic
procedures for unilateral and bilateral repair.
Several studies have demonstrated a definite advantage of
laparoscopic repair over open repair with regard to reduced post-
operative pain and earlier return to work and normal activities.
15e18
Laparoscopic repair also offers clear advantage in bilateral and also
recurrent inguinal hernia repairs.
19,20
Another major advantage of
the laparoscopic approach is the ability to detect and repair a
contralateral defect during the same operation, with only a mod-
erate increase in operating time.
21
More recently, minimally inva-
sive surgery can be performed using robotic technology with
potential benefits of enhanced visualization and improved dexter-
ity due to wristed instruments.
22
The first robotic-assisted TAPP inguinal hernia repair procedures
reported herein implemented a technique that was similar to
laparoscopic TAPP inguinal hernia repair, including port posi-
tioning.
23,24
The initial procedures showed the need for technical
modifications to prevent the robotic arm from clashing, and to
improve visualization and access to both groin sides. It was also
noted that placement of the mesh and sutures after docking would
increase the time of operation significantly since it would require
undocking a robotic arm to place them inside the abdomen. After
E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx4
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
the initial 10 cases, the appropriate technical modifications were
applied. The final technical modifications that were applied to the
last 10 cases decreased the time of operation substantially and
improved visualization and access to both sides of the groin, and
minimized robotic arm clashing. The time of operation for the last
robotic procedures that were performed according to the final
standardized technique (as described earlier) at the end of the
study was comparable to that of the laparoscopic approach.
This report demonstrated the safety, feasibility and reproduc-
ibility of the robotic-assisted TAPP inguinal hernia repair in selected
patients by an experienced surgeon. Robotic technology enables
the surgeon to offer minimally invasive inguinal hernia repair to
patients with higher BMI and larger hernias, which are technically
more challenging using the laparoscopic approach.
25
Performing
robotic-assisted TAPP inguinal hernia repair safely and efficiently
requires a long learning curve. However, for surgeons with
advanced laparoscopic skills, and with the adoption of measures
outlined in this report, this learning curve may become shorter. We
believe that an experienced surgeon with accessibility to advanced
robotic technologies, such as the da Vinci surgical platform, may
feel confident in performing more complex cases, such as ingui-
noscrotal hernias. This could consequently expand patient
selection, which in itself could increase the number of patients who
may benefit from minimally invasive inguinal hernia repair.
5. Conclusions
Robotic inguinal hernia repair is a feasible and safe procedure.
The operative time is significantly longer than for laparoscopic and
open techniques, and the additional costs are substantial. With the
adoption of the measures and the technique outlined in this report,
we believe it is feasible to shorten the operative time and the
surgeon's learning curve. Whether robotics may improve the out-
comes of minimally invasive inguinal hernia repairs, including
lowering recurrence rates, and decreasing postoperative pain, will
require future prospective investigation. If this will prove true, we
can say that there is a new era in the surgical management of
inguinal hernia.
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Table 1
Patient characteristics by procedure type.
Total (N ¼137) Open (N ¼97) Laparoscopic (N ¼16) Robotic (N ¼24) P value
Age, median (IQR) 55.0 (36.5e68.5) 55.0 (35.0e68.5) 48.0 (27.5e65.7) 60.0 (42.2e67.7) 0.876
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a
0.001
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a
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a
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b
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a
0.054
b
0.005
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b
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0 (0%)
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b
<0.001
Analgesics (per day) Median (IQR) 3.0 (2.0e3.0) 1.5 (1.0e2.0) 1.5 (1.0e2.0) 2.0 (2.0e3.0)
a
0.48
b
<0.001
a
Comparison between laparoscopic and robotic surgery.
b
Comparison between open, laparoscopic and robotic surgery
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Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
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E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx6
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
