Long-term outcomes of robotic inguinal hernia repair (r-TAPP): a retrospective review of 434 consecutive cases by a single surgeon with 3–8 years of follow-up

Abstract

When evaluating the long-term follow-up of robotic-assisted transabdominal preperitoneal (r-TAPP) approach to inguinal hernias, research remains limited due to small patient cohorts and shorter follow-up durations. The most significant research on inguinal hernia repair utilizing r-TAPP procedure includes follow-up periods of up to 2 years and examines approximately 150 cases. This article presents data from 434 consecutive r-TAPP procedures conducted on 324 patients, with follow-up ranging from a minimum of 3 years to 8 years. These procedures were performed between April 2016 and February 2021. Patients were seen in person for a follow-up appointment 2 weeks after surgery, with additional follow-ups conducted via phone at half a year, a full year, and yearly thereafter up to 8 years. Among the 324 patients, 107 patients presented with left-sided inguinal hernias (33%), 107 presented with right-sided inguinal hernias (33%), and 110 presented with bilateral inguinal hernias (33.95%). Patients’ ages varied between 25 and 96 years, and their BMI ranged from 17.7 to 50.2 (mean: 26.9, median: 26.2). Total procedure time varied from 35 to 191 min (mean: 62 min, median: 54 min). Within this, the docking time averaged 6 min, ranging from 3 to 15 min. The console time, which constitutes the primary operative phase, averaged 43 min, with a range of 11–183 min. The ASA scores varied between 1 and 3 (mean: 2, median: 2). None of the 324 patients experienced major blood loss, required conversion to open surgery, or had to stay overnight; every patient was sent home on the day of the procedure. Follow-up rates included 86.9% at 3 years, 87.1% at 4 years, 86.7% at 5 years, 86.4% at 6 years, 89.7% at 7 years, and 87.5% at 8 years. Two hernia recurrences were reported out of the 324 patients with 434 hernias performed, and no patients reported chronic pain between 3 and 8 years post-operation. The r-TAPP procedure provides a secure and efficient repair with a low recurrence rate (0.46%), reduced chronic pain, and competitive operative times. Compared to laparoscopic repair, which has a median operative time of 79 min, r-TAPP showed average times of 54 min for left-lateral hernias, 53 min for right-lateral hernias, and 79 min for bilateral cases (Kakiashvili et al.). While slightly longer than open repair (median time of 44 min), with differences of about 10 min for unilateral and 35 min for bilateral cases, r-TAPP offers superior precision and outcomes, making it a valuable option for inguinal hernia repair.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11701-025-02220-9.

Background/literature review

Inguinal hernias have been recognized throughout history, with references in ancient Egypt and Mesopotamia [12]. Advancements in anesthesia and antiseptic medicine in the nineteenth century enabled more complex surgeries, leading to Edoardo Bassini's development of the “Bassini repair” in the late 1800s, a pivotal technique in inguinal hernia surgery [11]. However, the Bassini repair had recurrence rates between 11.1% and 35.7% [4].

Later modifications by McVay and Shouldice reduced recurrence rates, but these tension-based techniques had limitations. The Shouldice technique achieved recurrence rates of less than 1% in specialized centers but up to 10% elsewhere [1]. Dr. Irving Lichtenstein’s tension-free repair using prolene mesh marked a breakthrough, with recurrence rates as low as 0% over 5 years, though drawbacks included larger incisions, more pain, and longer recovery times when compared to minimally invasive laparoscopic technique [2].

Laparoscopic techniques, such as transabdominal preperitoneal (TAPP) repair, reduce invasiveness with smaller incisions [6]. Recently, robotic-assisted techniques, including robotic TAPP (r-TAPP) and robotic eTEP (r-eTEP), have offered enhanced visualization and greater precision during surgery, leading to faster recovery times and lower recurrence rates [10].

Despite these advancements, the literature on r-TAPP for inguinal hernias remains limited, particularly regarding long-term outcomes. Many existing studies have follow-ups of only 2 years, and studies with larger sample sizes often have follow-ups of just 1 year, with procedures performed by multiple surgeons—introducing potential confounding variables.

This article aims to address these gaps in the current hernia literature. The longest study to date r-TAPP for inguinal hernias reported outcomes over 2 years for 150 hernias [5]. This article builds upon that study by analyzing 434 consecutive r-TAPP procedures performed on 324 patients using the Da Vinci Xi surgical robot, with follow-ups ranging from 3 to 8 years.

Methods

A total of 324 consecutive patients were studied between April 2016 and February 2021. The Da Vinci Xi Surgical Robot was used to treat these 324 patients, performing 434 r-TAPP procedures via robotic transabdominal preperitoneal (TAPP) repair for inguinal hernias. All patients had an in-person follow-up 2 weeks after the operation, with subsequent follow-ups conducted via phone at half a year, a full year, and yearly thereafter up to 8 years. Over the course of these check-ins, patients were asked about their recovery, specifically whether they experienced any chronic pain or symptoms related to the surgery. Those reporting concerns were asked to schedule an in-person appointment with the surgeon for further evaluation.

Procedure

The patient voids prior to surgery, is taken to the operating room and placed on their back with limbs extended. For male patients over 40 years of age, a Foley catheter was inserted, and the trocars were positioned in the upper part of the abdomen. The bed is positioned with a slight flex, with the individual placed in the Trendelenburg position prior to robot docking. Using a 0-degree scope, the center of the hernia is identified, and a point 8 cm above is marked to begin dissection. At this level, the area posterior to the rectus abdominis is accessed, and dissection continues laterally. At the level corresponding to the middle of the rectus abdominis muscle, the dissection is redirected to the pre-transversalis space. Medial dissection continues until the symphysis pubis is identified, followed by lateral dissection, with both directions eventually converging. The protrusion is then repositioned, and any fatty tissue around the spermatic cord is excised. The dissection continues downward to allow enough room for the mesh to lay flat without clam shelling, covering at least 2 cm horizontally and vertically across the midline and symphysis, respectively. The mesh is marked, folded, and placed, so that it covers the entire myopectineal orifice, with its center aligned over the defect and extending 2 cm horizontally and vertically across the midline and symphysis, respectively. The peritoneum is sutured closed and any residual CO₂ is evacuated from the extra-peritoneal space. The needles are removed, and the robotic system is undocked. The trocars are withdrawn, and the surgical incisions are sutured closed.

Results

Among the 324 patients, 107 patients presented with left-sided inguinal hernias (33%), 107 presented with right-sided inguinal hernias (33%), and 110 presented with bilateral inguinal hernias (33.95%) (Table 1). Patients’ ages spanned between 25 and 96 years, with BMI values fluctuating between 17.7 and 50.2. The mean BMI was 26.9, while the median was 26.2. The lowest American Society of Anesthesiologists (ASA) classification was recorded as 1, while the highest was 3; the average and median classifications were both 2. Procedure duration ranged from 35 to 191 min, with the mean and median times recorded as 62 and 54 min, respectively (Table 2).

Table 1.

Breakdown of patient lateralization and distribution within the patient cohort by hernia classification

Lateralization	Patient count (n)	Hernia count (n)	Patient representation (in %)	Hernia representation (in %)
Left	107	107	33%	24.65%
Right	107	107	33%	24.65%
Bilateral	110	220	33.95%	50.69%
Total	324	434	100%	100%

Table 2.

The range (minimum and maximum), average, and median values for patient factors and surgical metrics

	Age	BMI (kg/m2)	ASA	Procedure time (min)
Minimum	25.0	17.7	1	35
Maximum	96.0	50.2	3	191
Average	65.0	26.9	2	62
Median	66.0	26.2	2	54

The average procedure times were recorded at 54 min for left-lateral inguinal hernias, 53 min for right-lateral inguinal hernias, and 79 min for bilateral inguinal hernias (Table 3). The total operative time had an average of 62 min, with a range of 35–191 min. Within this, the docking time averaged 6 min, ranging from 3 to 15 min. The console time, which constitutes the primary operative phase, averaged 43 min, with a range of 11–183 min (Table 4). The procedure time for the majority of patients was under 49 min (Table 5). The majority of patients were in the 60–69 years age category when the surgical procedure occurred (Table 6).

Table 3.

Breakdown of average procedure time range (min) by lateralization

	Lateralization	Average time (minutes)
Left	107	54
Right	107	53
Bilateral	110	79

Table 4.

Operation time broken down into total operative time, docking time, and console time, including average and range

Time Category	Average (min)	Range (min)
Total Operative time	62	35–191
Docking	6	3–14
Console	43	11–183

Table 5.

Categorization of the patient cohort based on procedure time interval

Procedure time range (min)	Frequency
0–49	149
50–74	117
75–99	34
100–124	13
125–149	8
150–191	3

Table 6.

Breakdown of patients by age category

Age range (yrs)	Patient count (n)
20–29	5
30–39	16
40–49	31
50–59	50
60–69	89
70–79	80
80–89	49
90–99	4

Among the 324 consecutive r-TAPP patients, none experienced significant blood loss, required conversion to open surgery, developed a symptomatic hematoma or seroma that required reoperation, underwent reoperation for any other reason, or needed overnight hospitalization. However, out of 434 consecutive r-TAPP hernias studied, only two hernias recurred (0.46%) (Table 7). Follow-up rates were recorded at 86.9% at 3 years, 87.1% at 4 years, 86.7% at 5 years, 86.4% at 6 years, 89.7% at 7 years, and 87.5% at 8 years (Table 8). Calculations included 323 patients who responded to phone calls and one deceased patient who fell within the 3- to 8-year timeframe, specifically at year 7.

Table 7.

Postoperative complications

Complication type	Count (n)	Percentage (%)
Recurrence	2	0.46%
Hematoma	0	0%
Seroma	0	0%
Reoperation	0	0%
Significant blood loss	0	0%
Conversion to open surgery	0	0%
Overnight hospitalization	0	0%

Table 8.

Inguinal hernia percent follow-up interval from 3 to 8 years

Follow-up interval	3rd Year follow-up	4th Year follow-up	5th Year follow-up	6th Year follow-up	7th Year follow-up	8th Year follow-up
Patients (n)	324	311	247	172	96	14
Response (%)	86.9%	87.1%	86.7%	86.4%	89.7%	87.5%

Discussion

Hesitation to adopt the r-TAPP procedure persists due to concerns of increasing procedure time, and limited long-term data compared to L-TAPP or TEP. While a learning curve exists for mastering r-TAPP, it is significantly shortened due to its similarity to laparoscopic procedures, requiring only minor adjustments [9]. This is supported by Kudsi et al., who analyzed OR times for both groups and found that r-TAPP times closely align with traditional procedures, even when accounting for higher procedure volumes and increased complexity [8]. Additional evidence from Kakiashvili et al. further supports these findings. Our study demonstrates comparable procedural times to those observed in the laparoscopic procedure with similar laterality, as shown in Table 3. This paper extends the findings of a previous study, which reported follow-up data of 2 years involving 150 r-TAPP procedures [5]. That study found mean operative times of 55 min for left-sided inguinal hernias, 53 min for right-sided hernias, and 78 min for bilateral hernias. Despite the notable increase in the volume of hernias, as well as follow-up time in our study, the average operative times remained consistent, differing by only 1 min: 54 min for left-sided hernias, 53 min for right-sided hernias, and 79 min for bilateral hernias (Table 3). These findings strongly support the consistency of operative times after mastering the learning curve by demonstrating minimal impact on procedure times. Table 5 specifically represents the frequency distribution of patients across various time intervals. It is important to note that patients with procedure times exceeding 125 min during r-TAPP procedures were most likely undergoing repairs for recurrent posteriorly repaired hernias at other institutions. The average time required to repair recurrent hernias was 81 min, compared to 53 min for routine unilateral hernias and 78 min for bilateral hernias. Regarding seromas, as noted in Table 7, while seromas were observed, none required drainage. Patients were well informed prior to surgery about the possibility of seroma formation and were able to tolerate them until they naturally resolved. Additionally, in our study, OR times observed a decreasing trend as surgical experience increases.

All of the surgeries performed in this study were carried out using the da Vinci Xi Surgical System, a multi-port system. Surgical systems have continued to evolve over the years, with the development of the da Vinci SP (Single Port) system, designed for single-incision surgeries. Our group has explored and visited the Intuitive headquarters in California for a lab on the SP; however, no clinical experience with the SP has been conducted by our team.

Short-term outcomes of r-TAPP procedures are well documented in the literature, but gaps remain in long-term outcome data. One of the most significant studies to date reported follow-up data for 2 years, encompassing 150 r-TAPP procedures. Our study extends this follow-up period to include 434 r-TAPP procedures performed on 324 patients (Table 1), making it the longest follow-up reported to date. Despite this advancement, there are still some limitations to this paper. Although all procedures were conducted by a single surgeon, ensuring consistent surgical techniques, a study involving multiple surgeons performing the procedure would further substantiate the reliability of this data and support r-TAPP as a practical method for hernia repair.

Currently, the main barriers to the widespread adoption of r-TAPP for inguinal hernia repair are the (capital outlay for the purchase of the DaVinci Robot) and the learning curve required for surgeons to master the procedure. Bridging this gap will require demonstrating that r-TAPP offers superior outcomes, such as lower recurrence rates and enhanced patient safety, as surgeons overcome the learning curve. Additionally, studies highlighting the long-term cost-effectiveness of r-TAPP could further justify its implementation.

At this surgeon’s hospital, a 12-month study of laparoscopic versus robotic cases revealed that robotic cases were $100–$200 less expensive per case, with procedure times for routine cases being comparable or shorter. In this surgeon’s experience, r-TAPP has demonstrated significant advantages, particularly for complex inguinal hernia repairs, with no case conversions in over 800 repairs, a remarkably low recurrence rate of 0.46%, and no major complications—outcomes that surpass those often observed with laparoscopic techniques.

Given these benefits, public healthcare institutions should consider initiating a robotic inguinal hernia program. Robotic-assisted techniques, such as r-TAPP, provide enhanced surgical precision, improved patient safety, and better long-term outcomes. Although the learning curve is a factor, it enables surgeons to efficiently handle both routine and complex cases, with costs becoming comparable to or even lower than laparoscopic procedures over time. By adopting robotic-assisted surgery, institutions can position themselves at the forefront of surgical innovation, ultimately advancing patient care and expanding their capacity for effective hernia repair.

In spite of successful procedures, inguinal hernia repairs can result in recurrences which results in more hospital time, pain, and cost to the patient. An investigation by Kakiashvili noted a recurrence rate of 8.3% for robotic procedures, which is higher than the 3.1% and 0% rates for open and laparoscopic procedures, respectively [7]. A study with 665 patients investigating short-term outcomes from TEP procedures found that at 3 months the recurrence rate was 0.8% [3]. Our study, conducted by a single surgeon, included a sample of 434 inguinal hernias followed up from 3 to 8 years and had an outcome of 2 recurrences (0.46%).

Conclusion

This study's findings demonstrate that robotic transabdominal preperitoneal (r-TAPP) repair proves to be a reliable and efficient approach for treating inguinal hernias. r-TAPP offers advantages such as operating room times that are comparable to or shorter than laparoscopic repair, facilitation of same-day discharge, minimization of postoperative pain, and a low recurrence rate (0.46%). These outcomes support the viability of r-TAPP as an outpatient procedure for inguinal hernia repair.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Every author participated in the design and preparation of the study; this includes the gathering of data and preparation of material. O.V. was responsible for data analysis, which J.F., MD, FACS, and K.M. reviewed. K.M. and O.V. prepared the manuscript’s first draft, and all authors provided feedback on each version. The final draft of the manuscript was reviewed and approved by all authors.

Funding

This study's authors received no form of financial support before or during the manuscript’s composition.

Data availability

Data are presented in the supplementary information file, provided as a Microsoft Excel document, to support the results of our manuscript.

Declarations

Conflict of interest

Intuitive Surgical, Inc. provided author Jorge L. Florin, MD, with consultant and speaker compensation.

Ethical approval

An IRB exception was declared for this study. Verbal consent was received from patients during data collection, and all identifiable information was removed. Each study participant provided informed consent at the time of patient phone calls or clinic follow-ups.

Consent to publication

This study did not include any identifiable information from any participant in this study. The data collected from this study were authorized to be used for publication when contacted patients consented at the time of phone call or clinic follow-up.