Surgical Approach and Long-Term Recurrence After Ventral Hernia Repair

Abstract

Importance: The prevalence of robotic-assisted anterior abdominal wall (ventral) hernia repair has increased dramatically in recent years, despite conflicting evidence of patient benefit. Whether long-term hernia recurrence rates following robotic-assisted repairs are lower than rates following more established laparoscopic or open approaches remains unclear.

Objective: To evaluate the association between robotic-assisted, laparoscopic, and open approaches to ventral hernia repair and long-term operative hernia recurrence.

Design, setting, and participants: Secondary retrospective cohort analysis using Medicare claims data examining adults 18 years and older who underwent elective inpatient ventral, incisional, or umbilical hernia repair from January 1, 2010, to December 31, 2020. Data analysis was performed from January 2023 through March 2024.

Exposure: Operative approach to ventral hernia repair, which included robotic-assisted, laparoscopic, and open approaches.

Main outcomes and measures: The primary outcome was operative hernia recurrence for up to 10 years after initial hernia repair. To help account for potential bias from unmeasured patient factors (eg, hernia size), an instrumental variable analysis was performed using regional variation in the adoption of robotic-assisted hernia repair over time as the instrument. Cox proportional hazards modeling was used to estimate the risk-adjusted cumulative incidence of operative recurrence up to 10 years after the initial procedure, controlling for factors such as patient age, sex, race and ethnicity, comorbidities, and hernia subtype (ventral/incisional or umbilical).

Results: A total of 161 415 patients were included in the study; mean (SD) patient age was 69 (10.8) years and 67 592 patients (41.9%) were male. From 2010 to 2020, the proportion of robotic-assisted procedures increased from 2.1% (415 of 20 184) to 21.9% (1737 of 7945), while the proportion of laparoscopic procedures decreased from 23.8% (4799 of 20 184) to 11.9% (946 of 7945) and of open procedures decreased from 74.2% (14 970 of 20 184) to 66.2% (5262 of 7945). Patients undergoing robotic-assisted hernia repair had a higher 10-year risk-adjusted cumulative incidence of operative recurrence (13.43%; 95% CI, 13.36%-13.50%) compared with both laparoscopic (12.33%; 95% CI, 12.30%-12.37%; HR, 0.78; 95% CI, 0.62-0.94) and open (12.74%; 95% CI, 12.71%-12.78%; HR, 0.81; 95% CI, 0.64-0.97) approaches. These trends were directionally consistent regardless of surgeon procedure volume.

Conclusions and relevance: This study found that the rate of long-term operative recurrence was higher for patients undergoing robotic-assisted ventral hernia repair compared with laparoscopic and open approaches. This suggests that narrowing clinical applications and evaluating the specific advantages and disadvantages of each approach may improve patient outcomes following ventral hernia repairs.

Figure 1.. Overall Cumulative Incidence of Operative Recurrence Following Ventral Hernia Repair, Stratified by Approach (Robotic, Laparoscopic, and Open) From 2010-2020

Cumulative incidence of operative hernia recurrence was calculated using a Cox proportional hazards model that adjusted for patient age, sex, race and ethnicity, Elixhauser comorbidities, year of surgery, approach (robotic-assisted, laparoscopic, or open), mesh use, the use of myofascial flap, and procedure type (ventral/incisional or umbilical). Analysis included use of an instrumental variable to reduce measured and unmeasured confounding. The instrument used was robotic-assisted ventral hernia repair use rate within a hospital referral region in the 12 months prior to a patient’s initial ventral hernia repair. 95% CIs are not visible as the largest interval was −0.18% to 0.18% from point estimates.

Figure 2.. Cumulative Incidence of Operative Recurrence Following Ventral or Incisional Subtype Hernia Repairs Only and Umbilical Hernia Subtype Repairs Only, Stratified by Approach (Robotic-Assisted, Laparoscopic, and Open) From 2010-2020

Cumulative incidence of operative hernia recurrence following ventral or incisional (A) and umbilical (B) hernia repair was calculated using a Cox proportional hazards model that adjusted for patient age, sex, race and ethnicity, Elixhauser comorbidities, year of surgery, approach (robotic-assisted, laparoscopic, or open), mesh use, the use of myofascial flap, and hernia subtype (ventral/incisional or umbilical). Analysis included use of an instrumental variable to reduce measured and unmeasured confounding. The instrument used was robotic-assisted ventral hernia repair use rate within a hospital referral region in the 12 months prior to a patient’s initial ventral hernia repair. 95% CIs are not visible as the largest interval was −0.18% to 0.18% from point estimates for ventral and incisional subtype hernias and −0.14% to 0.14% from point estimates for umbilical-subtype hernias.