Surgical repair of inguinal hernias has evolved from open surgery to minimally invasive techniques. Current guidelines recommend laparoscopy for primary unilateral inguinal hernias owing to reduced postoperative pain, wound infection, and faster recovery compared with open repair [1]. Recent developments in minimally invasive techniques include the introduction of robotic platforms [2]. Notably, the da Vinci system (Intuitive Surgical) provides a magnified three-dimensional (3D) view, stable platform, and superior range of motion. Thus, surgeons may overcome the technical difficulties of laparoscopic hernia repair, which may result in better clinical outcomes [3,4].

Several studies have described the successful transition of surgeons from the laparoscopic to the robotic approach, demonstrating its feasibility while being safe [3,5]. Additionally, the number of patients undergoing robotic inguinal hernia repairs continues to increase despite its controversial clinical benefits [6]. However, reports also indicate that longer operative times and higher costs associated with robotic inguinal hernia repair negate its potential benefits [6,7]. Furthermore, despite the promising outcomes of robotic inguinal hernia repair, published data are limited to retrospective single-center series, and a quantitative analysis of its potential benefits is lacking [2,8].

Thus, we aimed to elucidate the outcomes of our experience with robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair to assess its safety and feasibility for inguinal hernia repair.

Study population

This was a retrospective review of R-TAPP inguinal hernia repair performed at National Health Insurance Service Ilsan Hospital between May 2022 and January 2023.

Review of patient data

Patient characteristics, including age, sex, body mass index, history of abdominal surgery, duration of symptoms, American Society of Anesthesiologists physical status classification, comorbidity, laterality, recurrent hernia, type of hernia, and contents of the hernia sac, were collected. Surgical outcomes, including operative time, docking time, console time, conversion to open surgery or laparoscopy, length of hospital stay, and postoperative complications, were analyzed. Postoperative complications were categorized as hematoma, seroma, ileus, spermatic vessel injury, urinary retention, inguinodynia, or recurrence. The operative time was recorded as the time from incision to dressing. Docking time was recorded as the time from the first order to push the robot toward the patient and ending with the actual start of the robotic procedure. Therefore, docking time included the correct positioning of the robot, connection of the robotic arms to the trocars, and installation of robotic instruments and the camera. Console time was recorded as the time from the start of the operation at console to the end of the operation at console. Urinary retention was defined as a case requiring Nelaton or Foley catheter insertion for voiding. Inguinodynia was defined as pain not relieved by oral medications and required at least one follow-up appointment with a surgeon. Recurrence was defined as an unambiguous bulging of the abdominal wall along the course of the inguinal canal with repositioning at relaxation and confirmed by ultrasonography or computed tomography.

Surgical procedure

All patients who underwent R-TAPP inguinal hernia repair underwent a standard transabdominal preperitoneal procedure under general anesthesia. All R-TAPP repairs were performed using the da Vinci Xi system with parallel-side docking. Patients were asked to void preoperatively, and Foley catheters were not routinely placed. Patients were positioned in a 10° Trendelenburg supine position, and both arms were tucked on their sides. Entry into the peritoneal cavity was achieved using an open method. We used a three-arm technique wherein the 0° scope was placed through the midline at the infraumbilical incision, and two additional ports were placed 8 cm to the left and right. Three 8-mm trocars were used (Fig. 1). After docking and inspecting both groins (Fig. 2), peritoneal dissection was initiated 8 to 10 cm above the internal inguinal ring, starting at the median umbilical fold and proceeding laterally toward the anterior superior iliac spine. Dissection was performed using monopolar scissors and a fenestrated grasper in the right and left hands, respectively. Dissection was extended inferiorly toward the deep inguinal ring, laterally toward the psoas muscle, and at least 2 cm between Cooper’s ligament and the bladder to facilitate adequate mesh overlap in the space of Retzius. The hernial sac and its corresponding peritoneal tissues were carefully dissected from their attachments, and the cord elements were parietalized by retracting the hernial sac from its orifice toward the mid-psoas muscle. If present, lipomas were either reduced or excised. After evaluation of the myopectineal orifice for any hidden hernias and visualization of all anatomical elements, a 3DMax (Bard Davol Inc.) mesh was placed around the spermatic cord from the pubic symphysis to the anterior iliac spine laterally without fixation. The peritoneal flap was closed using 4-0 V-Loc sutures (Covidien). The space was deflated under direct visualization without drainage. The incision was repaired with absorbable 3-0 sutures using a subcuticular method.

Patient follow-up

Patients were discharged after surgery without specific restrictions regarding mobilization or exercise. Patients were regularly followed up in the outpatient clinic one week postoperatively. Additional follow-up visits to the outpatient clinic were scheduled based on the postoperative clinical course of the patient.

Statistical analysis

The patient characteristics and surgical outcomes were summarized using continuous and categorical variables. Continuous variables are presented as mean and standard deviation, whereas categorical variables are presented as frequencies with percentages. Statistical analyses were performed using the software PASW SPSS ver. 18.0 (IBM Corp.).

Patient characteristics

Overall, 21 patients (20 male patients [95.2%]) with a mean age of 54.1 ± 16.4 years and a mean body mass index of 23.8 ± 1.9 kg/m² who underwent R-TAPP inguinal hernia repair were included in the study (Table 1). Bilateral hernias were observed in two patients (9.5%). One patient (4.8%) had hernia recurrence after Lichtenstein hernioplasty.

Intraoperative details

Intraoperatively, 10 patients (47.6%) underwent indirect hernia repair, and six patients (28.6%) underwent scrotal hernia repair (Table 2). The mean duration of symptoms of those with a scrotal hernia was 72.0 ± 78.5 months. The most common content of hernia sac was omentum (28.6%). A sigmoid colon sliding hernia was present in three patients (14.3%). The mean operation, docking, and console times were 91.8 ± 20.4 minutes and 154.5 ± 26.2 minutes, 13.2 ± 4.2 minutes and 15.5 ± 0.7 minutes, and 61.4 ± 16.9 minutes and 128.0 ± 25.5 minutes for unilateral and bilateral hernia repair, respectively. No conversions to open surgery or laparoscopy were noted. The mean length of hospital stay was 3.8 ± 0.9 days.

Postoperative complications

Table 3 presents the postoperative complications. A wound seroma developed in one patient, but it was managed conservatively and had resolved at the 1-month follow-up. Postoperative ileus developed in one patient but spontaneously resolved 2 days after surgery. Spermatic vessel injury was identified in one patient intraoperatively; however, the patient was managed conservatively, and there were no related complications thereafter. No recurrence was observed during the study period.

In this study, we demonstrated that R-TAPP helped achieve favorable outcomes for inguinal hernia repair without causing major complications. Previously, only minor postoperative complications have been reported. Collectively, our findings suggest that R-TAPP hernia repair is feasible for scrotal and sigmoid colon sliding hernias and may be a safe and feasible method for patients with inguinal hernias.

A robotic system offers magnified 3D visualization, a stable platform, and increased dexterity with 7 degrees of freedom in the articulating wrist. Consequently, a robotic system may help better visualize the groin anatomy and improve the comfort and performance of the surgeon. Previous studies reported that robotic platforms consistently demonstrate faster suturing than standard laparoscopy [9]. The use of robots for inguinal hernia repair has demonstrated promising outcomes, although data are limited owing to the novelty of the robotic approach for hernia repair [10]. One barrier to the adoption of robotic platforms is the associated learning curve. The learning curve of R-TAPP is estimated to range from 30 to 40 cases based on the duration of the surgery [11]. In the current study, the mean operative time was slightly longer than that previously reported for R-TAPP repair [2]. However, the operative time is expected to decrease after overcoming the learning curve.

Previous reports have noted the advantages of a robotic approach for more complex clinical scenarios, such as recurrent inguinal hernia, incarcerated hernia, large scrotal hernia, and history of abdominal surgery during inguinal hernia repair. Repair of complex inguinal hernias is challenging because a large scrotal hernia usually contains the omentum or bowel and is difficult to reduce during surgery owing to its adhesion to the hernia sac [12]. Repair of a recurrent inguinal hernia and in patients with a history of abdominal surgery repair, such as radical prostatectomy, is also challenging owing to adhesions and scar tissue [13,14]. Therefore, only highly skilled surgeons perform laparoscopic inguinal hernia repair in these patients [15]. However, a robotic approach may decrease the risk of damage to the myopectineal orifice by enhancing 3D vision. The grip and pulling power of a robotic instrument are stronger than that of a laparoscopic instrument and can overcome complex situations that are challenging to perform laparoscopically.

Dewulf et al. [16] reported that R-TAPP inguinal hernia repair demonstrated comparable outcomes in patients with a history of transabdominal prostatectomy in terms of the postoperative complications of Lichtenstein hernia repair. Vitiello et al. [13] reported that R-TAPP recurrent inguinal hernia repair has comparable postoperative outcomes to laparoscopic repair and is associated with a low rate of postoperative and chronic pain without significantly increasing the operative time. Concordantly, we demonstrated that six scrotal hernias and three sliding hernias (42.9%) were corrected with R-TAPP repair without causing significant postoperative complications. Therefore, a robotic approach may improve the ergonomics of repairing complex inguinal hernias. Further studies are required to elucidate the potential advantages of robotic systems in more complex clinical scenarios involving inguinal hernias.

The present study has several limitations. First, it was performed at a single center, and the sample size was small; therefore, the results cannot be generalized. Second, this study did not include a comparative operative arm. Third, we could not evaluate the costs of the procedure and surgeon frustration. Finally, the outcomes of R-TAPP hernia repair in a Korean population might not be generalizable to other populations, notably non-Asians with a larger body surface area.

Our experience with R-TAPP hernia repair shows its feasibility as a minimally invasive alternative for inguinal hernia repair. Additionally, a robotic platform may be beneficial for complex hernia cases. Further studies are required to validate the benefits of R-TAPP hernia repair in terms of cost-effectiveness and optimal procedural steps.

Ethical statements

We conducted this study in compliance with the principles of the Declaration of Helsinki. This study was approved by the Institutional Review Board of National Health Insurance Service Ilsan Hospital (NHIMC2023-03-050). Written informed consent was obtained from the patients for the publication of this study including all clinical images.

Authors’ contribution

Conceptualization, Formal analysis, Methodology, Visualization, Data curation, Investigation: SJ, JHL

Writing–original draft: SJ, HSL

Writing–review and editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.

Patient characteristics

Intraoperative details and postoperative outcomes (n = 21)

Postoperative complications (n = 21)