Comparing robotic to open retromuscular ventral hernia repair: a multi-center propensity-matched analysis.

Introduction: Robotic retromuscular ventral hernia repair (r-RVHR) may benefit patients by converting an open surgery (o-RVHR) to a minimally invasive approach. Current comparative trials are limited by small patient cohorts and exploratory outcomes. This study compares short- and long-term outcomes of robotic versus open retromuscular ventral hernia repairs using a nationwide registry.

Methods: This propensity-matched analysis compared patients who underwent robotic or open ventral hernia repair with retromuscular mesh placement using Abdominal Core Health Quality Collaborative registry data (2014-2021). Groups were matched according to body mass index, Ventral Hernia Working Group classification, wound class, diabetes, smoking status, hernia width, and recurrent hernia repair. Primary outcome included hernia recurrence risk up to five years postoperatively evaluated two ways: 1) clinical/radiographic assessment only and 2) a pragmatic definition incorporating patient-reported bulging. Secondary outcomes included length of stay, wound morbidity, and patient-reported outcomes.

Results: 1228 r-RVHR patients were matched to 1228 o-RVHR patients. Robotic RVHR was associated with longer operative times (p < 0.001), reduced length of stay (1 vs 3 days; p < 0.001), 30-day surgical site infection rates (1.7% vs 3.4%; p = 0.013), and surgical site occurrences (SSO) requiring procedural intervention (1.9% vs 3.6%; p = 0.011), but higher overall SSO (16.4% vs 11.0%; p < 0.001). Robotic RVHR showed similar two-year pragmatic recurrence rates but higher recurrence risk after three years (HR 1.46, 95% CI 1.15-1.85, p = 0.002) with no difference in clinical recurrence risk. Transversus abdominis release and surgeon experience were independently associated with reduced recurrence risk regardless of surgical approach. At five years, r-RVHR patients reported worse quality of life scores (78 vs 90; p = 0.044). Both groups experienced significant follow-up attrition over time.

Conclusion: Robotic RVHR is associated with improved early post-operative outcomes yet may be associated with higher long-term pragmatic recurrence rates compared to open RVHR. These findings require investigation through prospective randomized trials with robust long-term follow-up.