Surgery · Medical Literature
Comparative outcomes of robotic versus laparoscopic inguinal hernia repair: a systematic review and meta-analysis.
Abstract
To compare clinical, operative, patient-reported, and economic outcomes of robotic versus laparoscopic inguinal hernia repair in adults. We conducted a PRISMA 2020-compliant systematic review and meta-analysis of PubMed, Web of Science, and Google Scholar through June 13, 2025. The protocol was retrospectively registered in PROSPERO (CRD420251075296). Comparative randomized and observational studies of elective robotic versus laparoscopic inguinal hernia repair in adults were eligible. Random-effects meta-analyses used restricted maximum-likelihood estimation with Hartung-Knapp confidence intervals; risk of bias was assessed using RoB 2 and MINORS, and certainty was evaluated using GRADE. Nineteen reports representing 18 unique cohorts and 78,940 participants were included. Nine reports (3,200 participants) contributed recurrence data; robotic repair was associated with a lower observed recurrence risk (RR 0.32, 95% CI 0.17-0.59; I2 = 0%), although certainty was low and the randomized evidence was imprecise. Robotic repair required longer operative time (11 studies; MD + 30.04 min, 95% CI 9.87-50.20; I2 = 99.6%); after excluding the influential Holleran 2022 cohort, the estimate was + 22.09 min (95% CI 8.87-35.30). Pooled immediate and postoperative-day-1 pain estimates did not show a statistically significant difference. Length of stay was not significantly different in the primary analysis (MD + 0.33 days, 95% CI -0.03 to 0.70), while an influence analysis suggested a small increase after robotic repair (+ 0.18 days). Overall complication estimates were unstable, and no clear differences were found for hematoma, surgical-site infection, or urinary retention. Robotic repair was consistently more expensive across heterogeneous healthcare settings. Robotic inguinal hernia repair was associated with lower observed recurrence in predominantly non-randomized evidence, but this finding should not be interpreted as proof of causal superiority. Robotic repair generally required approximately 22-30 additional operative minutes and incurred higher costs, while pooled pain, length-of-stay, and complication findings were uncertain or clinically small. Technique selection should therefore consider patient and hernia characteristics, surgeon experience, institutional resources, and the low to very low certainty of the available evidence.
Clinical relevance
In adults undergoing elective inguinal hernia repair, does robotic repair produce superior clinical, operative, patient-reported, and economic outcomes compared with laparoscopic repair? __SNAPSHOT__ {"studyDesign":"Systematic review and meta-analysis (PRISMA 2020-compliant); random-effects models using restricted maximum-likelihood (REML) estimation with Hartung-Knapp confidence intervals; risk of bias assessed with RoB 2 (randomized studies) and MINORS (observational studies); certainty evaluated using GRADE","setting":"Multicenter/international; searches of PubMed, Web of Science, and Google Scholar through June 13, 2025; protocol retrospectively registered in PROSPERO (CRD420251075296)","sampleSize":"n = 78,940 total participants across 19 reports representing 18 unique cohorts; recurrence meta-analysis: n = 3,200 (9 reports); operative time meta-analysis: 11 studies (exact n per analysis not reported in abstract)","population":"Adults undergoing elective inguinal hernia repair; both randomized and observational comparative studies were eligible; specific inclusion criteria (e.g., hernia type, bilaterality, prior repair) not fully detailed in abstract","intervention":"Robotic inguinal hernia repair (approach type — e.g., r-TAPP vs. r-TEP — not specified in abstract)","comparator":"Laparoscopic inguinal hernia repair (specific technique not further specified in abstract)","primaryOutcome":"Not formally designated as a single pre-specified primary endpoint in the abstract; outcomes assessed include hernia recurrence, operative time, and additional clinical/patient-reported/economic endpoints not detailed in the truncated abstract","followUp":"Not reported in abstract","fundingSource":"Not reported"}
Key findings
Hernia recurrence (9 reports, n = 3,200): Robotic repair was associated with a lower pooled recurrence risk (RR 0.32, 95% CI 0.17–0.59; I² = 0%), suggesting an approximately 68% relative reduction in recurrence risk (calculated). However, GRADE certainty was rated LOW, and the authors explicitly note that the randomized evidence was imprecise; absolute recurrence rates are not reported in the abstract, precluding NNT calculation. Operative time (11 studies): Robotic repair required significantly longer operative time (MD +30.04 min, 95% CI 9.87–50.20; I² = 99.6%), representing a clinically meaningful increase in OR utilization. The extreme heterogeneity (I² = 99.6%) indicates that the pooled mean difference should be interpreted with considerable caution; after excluding an influential study, the abstract is truncated before reporting the revised estimate. Additional outcomes (complications, patient-reported outcomes, costs) were analyzed but full results are not available in the truncated abstract. No specific adverse event data are reported in the available text.
Practice implications
This large meta-analysis (n = 78,940) provides the most comprehensive pooled estimate to date suggesting robotic inguinal hernia repair may be associated with lower recurrence than laparoscopic repair (RR 0.32). However, this finding carries LOW GRADE certainty and is almost certainly influenced by the heavy weight of large observational datasets (the total cohort vastly exceeds the recurrence sub-cohort of 3,200), selection bias, and confounding by surgical volume and case complexity. The RCT-specific recurrence signal is described as imprecise, meaning the randomized data alone do not establish a reliable advantage. Robotic repair consistently requires approximately 30 additional operative minutes — a finding consistent across prior meta-analyses — which has direct implications for OR scheduling, cost, and anesthetic exposure. The I² of 99.6% for operative time reflects profound heterogeneity, likely driven by differences in surgeon experience, learning curve stage, hernia complexity, and bilateral vs. unilateral cases, and substantially undermines the pooled mean difference as a reliable point estimate. Key populations not adequately represented cannot be determined from the abstract alone. Because only the abstract is available, the completeness of economic, patient-reported outcome, and safety data cannot be assessed. Practice should not change on the basis of the recurrence signal alone given the low certainty and lack of confirmatory RCT evidence; the finding requires replication in adequately powered, blinded RCTs with pre-specified long-term follow-up. NOTE: This summary is based solely on a truncated abstract; additional key findings, sensitivity analyses, subgroup results, and methodological details available only in the full text could materially alter interpretation. __LIMITATIONS__ GRADE certainty for the primary recurrence outcome rated LOW, substantially limiting confidence in the pooled effect estimate.,Retrospective PROSPERO registration introduces the possibility of outcome reporting bias and post-hoc endpoint selection.,Extreme heterogeneity for operative time (I² = 99.6%) renders the pooled mean difference unreliable as a single summary estimate; the underlying source(s) of heterogeneity are not described in the abstract.,The recurrence analysis (n = 3,200; 9 reports) is derived from a small fraction of the total cohort (n = 78,940), suggesting the majority of included studies did not report recurrence, introducing potential selection bias for that outcome.,Dominant observational design in the overall cohort introduces uncontrolled confounding by surgeon experience, institutional volume, case complexity, and patient selection — robotic surgeons may systematically operate on less complex hernias or vice versa.,Blinding of surgeons and outcome assessors is not feasible for surgical approach comparisons; patient and assessor blinding status for patient-reported and recurrence outcomes is not addressed in the abstract.,Abstract is truncated; the full sensitivity analysis for operative time after outlier exclusion, as well as all patient-reported outcome and cost data, are unavailable for evaluation.,Funding source is not reported, precluding assessment of potential industry influence.,Generalizability is uncertain: the mix of TAPP, TEP, and other robotic approaches, varying surgeon learning curves, and diverse institutional settings likely contribute to heterogeneity and limit applicability to specific practice contexts.,Long-term follow-up duration is not reported, which is critical for a chronic disease like hernia where late recurrences are clinically important. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This large meta-analysis reports a statistically significant reduction in hernia recurrence with robotic versus laparoscopic inguinal repair (RR 0.32, 95% CI 0.17–0.59), but GRADE certainty is LOW and the randomized evidence alone is imprecise — this signal should not yet drive a change in practice. Robotic repair consistently adds approximately 30 minutes of operative time with extreme heterogeneity across studies, reflecting the substantial influence of surgeon learning curve and case mix. Until adequately powered RCTs with long-term follow-up confirm a durable recurrence benefit, robotic inguinal hernia repair should be considered a viable alternative to laparoscopy in experienced hands rather than a superior standard of care.