Efficacy and safety of robot-assisted versus endo-laparoscopic ventral hernia repair: a meta-analysis of randomized controlled trials

Abstract

Purpose

To comprehensively compare the surgical outcomes of robotic ventral hernia repair (rVHR) with traditional endo-laparoscopic ventral hernia repair (lapVHR) using systematic review methods, evaluating the efficacy and safety of rVHR and providing reference for clinical applications of rVHR.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) list. The following electronic databases were searched: PubMed, Web of science, Cochrane library, Embase, Scopus, and SpringerLink. The retrieval period spanned from the inception of database until 2024. Only randomized controlled trials were included. Outcomes of recurrence, re-hernioplasty, operative time, length of hospital stay and surgical site occurrence were compared between rVHR and lapVHR.

Results

A total of 5 studies (237 patients) were included in the meta-analysis. Compared with lapVHR, the treatment of rVHR significantly decreased re-hernioplasty (RR = 0.17, 95% CI 0.04–0.66). Additionally, rVHR significantly reduced the length of hospital stay (MD = 0.48, 95% CI: 0.25, 0.71) and operative time (MD = 69.45, 95%CI: 45.76, 93.14). In addition, rVHR can reduce the recurrence rate, but it is a marginal statistical difference (RR = 0.46, 95% CI: 0.19, 1.13).

Conclusion

Overall, both rVHR and lapVHR were effective and safe. Nevertheless, rVHR shows superiority in terms of recurrence rate and re-hernioplasty rate. More high-quality studies are warranted to validate the results of this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-025-02997-4.

Introduction

Ventral hernias, which comprise both primary and incisional hernias, present a high incidence rate with repair procedures ranging from day surgeries to extremely complex reconstructions [1]. While literature confirms the effectiveness of conventional laparoscopic hernia repair, it also highlights notable drawbacks, including limited surgical maneuverability and an extended learning curve, especially in complex scenarios [2]– [3].

In recent years, with the advancement of minimally invasive surgery (MIS), robotic-assisted laparoscopic surgery (RALS) has been introduced. Compared to traditional laparoscopy, robotic systems offer enhanced precision, three-dimensional visualization, and improved dexterity, potentially reducing postoperative pain and accelerating recovery [4]. The robotic-assisted accuracy minimizes tissue damage and mechanical injury, leading to less inflammation and perioperative discomfort compared with traditional laparoscopic hernia repair [5]. Smaller incisions and reduced surgery time further decrease pain and risk of infection, contributing to a faster recovery speed and improved surgical outcomes [6].

As the applications of robotic surgery increases, some limitations have become evident. Although robotic surgery seems to offer more precise techniques with increased intraoperative access and tactile sensation than traditional laparoscopic repair surgery, its longer operative times, higher costs, and operator preferences remain significant problems to address [7]. Up to date, specific data regarding outcomes for hernia repair remain insufficient. This systematic review and meta-analysis aimed at assessing the effectiveness and safety of robotic approaches (rVHR ) in the treatment of ventral hernias with the comparison to laparoscopic approaches (lapVHR).

Methods

This systematic review adhered to Cochrane guidelines [8] and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) list [9]. Each study was carefully reviewed and evaluated for quality of evidence and rigor of study design, including enrollment criteria, intervention, and reports of outcomes permitting uniform application of meta-analysis criteria. This study was registered in PROSPERO (CRD 420251019743).

Search strategy

A comprehensive literature search was conducted on major databases including PubMed, Web of science, Cochrane library, Embase, Scopus, and SpringerLink. The retrieval period spanned from the inception of database until December 31, 2024. A combination of Medical Subject Headings (MeSH) terms and non-MeSH terms using Boolean operators were used in PubMed. Search terms included: Abdominal Hernias; Hernias, Abdominal; Abdominal Wall Hernias; Abdominal Wall Hernia; Hernia, Abdominal Wall; Hernias, Abdominal Wall; Abdominal Hernia; Operation; Surgery; Robotic. No language restrictions were used. The detailed retrieval strategy for each database is shown in supplementary Table 1.

Inclusion and exclusion criteria

Randomized controlled trials (RCTs) were included. The treatment group was treated with rVHR, while the control group was set as those who received traditional lapVHR. Animal studies, case series, case reports, and retrospective studies were excluded. After the screening of titles and abstracts, studies that did not meet the inclusion criteria were excluded. For studies not excluded in the initial screening, full texts were reviewed. Finally, decisions on whether to include studies in our analysis were made strictly according to the inclusion and exclusion criteria. Two researchers (Junfeng LI and Shihong LI) completed these tasks independently, and a third researcher (Lunwu WEI) decided if there was a disagreement. These are supplemented in the Methods section.

Data extraction and outcome indicators

All included patients had abdominal hernia, regardless of age, sex, or race. Two reviewers independently extracted data from the study population (sample size, type of study, the type of surgical method (observation group), the type of surgical method (control group), exposure factors). The clinical outcomes included surgical site infection, re-hernioplasty, recurrence, length of hospital stay (Day), and operative time. These results were the most common and meaningful for evaluating the therapeutic effectiveness of the surgery. Any disputes were first discussed between the two researchers, and a third reviewer made the final decision if a consensus could not be reached. Two researchers (Junfeng LI and Shihong LI) completed these tasks independently, and a third researcher (Lunwu WEI) decided if there was a disagreement. These are supplemented in the Methods section.

Risk of bias assessment

Rob 2 (Risk of Bias 2.0 tool) was assessed using the Cochrane risk of bias assessment tool for corresponding studies. This tool assesses the risk of bias in five domains: Bias arising from the randomization process, Bias due to deviations from intended interventions, Bias due to missing outcome data, Bias due to missing outcome data, reporting bias (Selective reporting), and other sources of bias. The assessment is independently completed by two researchers, and any disagreements are resolved through discussion.

Statistical analysis

Meta-analysis was conducted using R (version 4.23) and meta package. Risk ratios (RR) were used to calculate the risk ratio for dichotomous outcomes (SSI, recurrence, re-hernioplasty), and mean differences (MD) were used for continuous variables (length of Hospital Stay and operative Time), both with 95% confidence intervals (CI) [10]. Statistical heterogeneity was assessed using the I² statistic, where I² values of 0–25% (low heterogeneity), 25–50% (moderate heterogeneity), and > 50% (significant heterogeneity) were defined. When significant heterogeneity was observed, a random-effects model (using the Der Simonian-Laired method) was employed [11]. Publication bias was tested using funnel plots. When more than 10 studies were included, the Egger’s regression test was used additionally. A P-value less than 0.05 in the results was considered statistically significant, indicating the presence of publication bias in the study.

Results

A total of 632 records were initially identified through database searching. Based on the predetermined screening criteria, 21 studies met the eligibility standards. Among these, 5 were excluded due to the inability to access the full articles, 4 meta-analyses, 2 review studies, 2 PSM studies, 1 study protocol, and 2 open surgeries were also excluded. As a result, 5 studies were determined for the qualitative and quantitative synthesis (Fig. 1). Of the 5 studies, 3 reported outcomes at different time points (1 month, 12 months, and 24 months) in the same population, for a total of 3 study designs. A total of 237 subjects were involved, of which with 114 patients having undergone lapVHR and 123 patients having undergone rVHR. Their characteristics are presented in Table 1. We used the ROB 2.0 tool to evaluate the quality of the literature, and all the included literature were of medium to high quality (Fig. 2).

Fig. 1.

PRISMA flow diagram

Table 1.

Basic characteristics of included literature

Trial registration	Author and Year	Sample size (observation/control)	BMI (invention/control)	Male/Female	Follow-up	Operator Training	Size of overlap	Reference
NCT03490266	Olavarria 2020	124(65/59)	32.4/31.8	39/85	1 months	Three high-volume, minimally invasive surgeons with 50 standardized repairs as a ramp-up period	At least 5 cm of overlap and closed by absorbable sutures	[15]
	Dhanani 2023/2021	101(54/47)		45/56	12 months	Three surgeons experienced in minimally invasive hernia with 50 standardized repairs as a ramp-up period	At least 5 cm of overlap on all sides relative to the hernia defect and closed by absorbable sutures	[12/13]
5,200,658	Käkelä 2023	38(18/18)	29.2 ± 5.3/30.0 ± 5.1	15/23	24 months	Two surgeons with good expertise in laparoscopic and robotic assisted surgery.	At least 5 cm above and below the hernia in order to allow adequate mesh overlap and closed by absorbable sutures	[14]
NCT03283982	Petro 2020	75(39/36)	31/35	34/41	12 months	One of the enrolling surgeons had several years of robotic experience while the other was in their first year of clinical practice after completing an abdominal wall reconstruction fellowship	With 5 cm of overlap from the initial measurement prior to defect closure and closed by absorbable sutures	[16]

Fig. 2.

Risk of bias of enrolled study

Recurrence

Recurrence was reported in 5 studies. Of these studies, 2 reported recurrence rate at 1 month, 2 at 12 months, and 1 at 24 months. The analysis results showed that the RR at 1 month was 0.31 (95% CI: 0.01, 7.32); the RR at 12 months was 0.64 (95% CI: 0.20, 2.05); the RR at 24 months was 0.29 (95% CI: 0.06, 1.37), and the combined overall RR was 0.46 (95% CI: 0.19, 1.13, p = 0.091) (Fig. 3a).

Fig. 3a.

Forest plots of outcomes: recurrence

Re-hernioplasty

Re-hernioplasty was reported in 5 studies. Of these studies, 2 reported re-hernioplasty rate at 1 month, 2 at 12 months, and 1 at 24 months. The analysis results showed that the RR at 1 month was 0.31 (95% CI: 0.03, 2.89); the RR at 12 months was 0.15 (95% CI: 0.02, 1.28); the RR at 24 months was 0.08 (95% CI: 0.00, 0.55), and the combined overall RR was 0.17 (95% CI: 0.04, 0.66, p = 0.011) (Fig. 3b).

Fig. 3b.

Forest plots of outcmes: Re-hernioplasty

Length of hospital stay (Day) and operative time (Min)

Length of hospital stay and operative time was reported in 5 studies. Due to the fact that the three studies were the same study subject, three hospital stays and operative time were analyzed. NCT03490266 did not report the specific length of hospital stay, just suggesting no difference in days in hospital between the two groups. The length of stay in two studies was analyzed. It suggested that rVHR significantly decreased the length of hospital stay compared to lapVHR (Table 2). The operation time of three studies were analyzed and indicating shorter operative time in rVHR group (Overall MD = 69.45, 95%CI: 45.76, 93.14, p < 0.001)(Fig. 3c).

Table 2.

Summary of length of hospital stay (Day)

Author and year	n	Mean Difference	95% CI
Käkelä 2023	38	0.30	-0.07, 0.67
Petro 2020	75	0.60	0.30, 0.90
Overall	113	0.47	0.18, 0.76

Fig. 3c.

Forest plots of outcomes: Operative Time (Min)

Surgical site infection

Four studies reported infection of surgical site as an outcome, two studied reported infection of surgical site at 1 month, one at 12 months and one at 24 months. At all follow-up times, there was no significant difference in surgical site infections between the two groups (Overall RR: 0.80, 95%CI: 0.12, 5.07, p = 0.809) (Fig. 3d).

Fig. 3d.

Forest plots of outcomes: Surgical site infection

GRADE assessment

The GRADE evaluation revealed moderate certainty for recurrence and length of hospital stay, primarily due to small sample sizes and wide confidence intervals. Re-hernioplasty and surgical site infection outcomes were rated as low certainty, influenced by high risk of bias in some studies (e.g., lack of blinding) and imprecision. Operative time showed high certainty due to consistent results across studies with minimal heterogeneity. Detailed GRADE profiles are available in Supplementary Table 2.

Discussion

In this study, through comparative analysis of relevant RCTs, the clinical outcomes of application of robotic-assisted laparoscopic approach versus traditional laparoscopic approach in VHR surgery was examined.

In the present study, the recurrence was a little lower than those for the lapVHR. Robotic surgery provides a precise three-dimensional view, allowing surgeons to achieve a more meticulous and complete fascial closure [17]. Robotic-assisted surgery offers distinct advantages in achieving secure fascial closure, a critical determinant in minimizing hernia recurrence by ensuring optimal reinforcement of the abdominal wall defect [18]. While both laparoscopic and robotic approaches allow mesh placement in retromuscular or preperitoneal spaces, robotic systems may enhance precision in complex cases [19]. This precise positioning lays the foundation for better integration of the mesh with surrounding tissues, reducing the mesh displacement and failure [20, 21]. The minimally invasive nature of robotic surgery results in less tissue damage and a lower level of inflammatory response than open procedures. Less inflammation leads to better wound healing, with fewer adhesions and scar formation, further reducing the risk of hernia recurrence [22]. A recent study published in JAMA Surgery (2024) with a median follow-up of 5 years reported significantly higher recurrence rates in rVHR compared to lapVHR [23]. This finding diverges from our meta-analysis. The median follow-up duration in our included studies was 24 months, which may be insufficient to detect late-onset recurrences.

In the present study, patients undergoing robot-assisted laparoscopic procedures experienced significantly longer hospital stays than those treated with traditional laparoscopic methods, which was not consistent with most previous reports [24]. As greater stability and precision, robotic surgical platforms minimize adverse events caused by hand tremors or fatigue. This increased control allows for more accurate handling of delicate structures, reducing tissue damage and postoperative inflammation with faster recovery [25]. Reduced physiological impact on patients in robotic surgeries results in a smoother postoperative recovery process than traditional laparoscopic methods, with less intensive care, faster rehabilitation and less pain management.

The operative time in our study tended to be longer in rVHR group. This is not the first time these results have been reported. Chen et al. [21]compared da Vinci robotic-assisted laparoscopic repair for small ventral hernias with traditional laparoscopic repair in terms of mesh circumferential suturing. Their results showed that the average operative time for the former was 156 min, significantly longer than the latter (65 min). This difference may be attributed to that rVHR requires time for setting up and calibrating the robotic system, including positioning the robotic arms, adjusting the operating table, and calibrating the system [25]. These steps are crucial for ensuring system precision and stability. Extended monitoring of patients after robotic surgery is necessary to ensure the effectiveness of the surgery and recovery, which may further increase operating room time [23]. In addition, exploring methods to shorten the operation time, such as strengthening learning and rational division of labor, are also the focus of research.

There was no significant difference in the incidence of surgical site infection between the two treatment modalities, which may be related to the small number of included literature and sample size. As an important consideration factor in hernia repair, postoperative site infection has been discussed in a few studies. Dhanani et al. [12] conducted a randomized controlled trial and reported the long-term outcomes of robotic ventral hernia repair, in which patients in the robotic group required fewer treatments for wound complications than that in laparoscopic group, while there were no significant between-group differences for other complications. Other studies also suggested improved surgical site outcomes for robotic-assisted fascial closure [17, 19–22]. The lower rate of surgical site infection (SSI) in robotic repair compared to laparoscopic surgery may be attributed to several advantages of the robotic platform. First, the articulating instruments of the robotic system overcome the angular constraints associated with traditional laparoscopic surgery, which potentially aids in achieving more successful closure of hernia defects [26]. Second, the ergonomic enhancements of the robotic platform facilitate manipulation of difficult anterior abdominal wall anatomy and significantly improve intra-abdominal suturing techniques [27].

A well-executed fascial closure, which is more consistently achievable with robotic assistance, plays a crucial role in reducing SSI rates. Proper fascial closure acts as a mechanical barrier that prevents exposure of internal tissues to external bacteria and contaminants [28]. Additionally, it reduces dead space within the wound, minimizing fluid accumulation that could promote bacterial growth. The precise tissue approximation achieved through robotic techniques also enhances wound healing by ensuring better alignment of wound edges, reducing tension on surrounding tissues, and supporting more efficient tissue repair [29].

Moreover, secure fascial closure helps maintain adequate blood supply to the wound area, which is essential for delivering immune cells and nutrients that aid in infection prevention. It also prevents complications such as evisceration or herniation, which could otherwise increase infection risk. Finally, by minimizing excessive inflammatory responses, proper fascial closure helps preserve robust immune function at the surgical site, further decreasing susceptibility to infection [30].

Our study demonstrated that robotic adhesiolysis presents several advantages over laparoscopic adhesiolysis, particularly in complex cases requiring extensive fascial dissection and large mesh implantation, making rVHR a preferable option [26, 27]. The robotic approach offers multiple technical benefits, including more intuitive instrument control, superior visualization capabilities, and integrated simulator training options, all of which contribute to a significantly shorter learning curve compared to conventional laparoscopic techniques [27]. Importantly, the robotic system helps mitigate several subjective factors that can influence surgical outcomes, such as the surgeon’s individual experience level, baseline laparoscopic skills, and the ability to manage specific procedural challenges. These inherent advantages of the robotic platform make it particularly suitable for complex ventral hernia repairs where precision and consistency are paramount [31]. The robotic platform demonstrates superior surgical precision owing to its enhanced motor control and exceptional instrument stability, enabling surgeons to perform meticulous adhesiolysis while minimizing trauma to adjacent anatomical structures. This technical advantage stands in contrast to conventional laparoscopic systems, which typically rely on two-dimensional visualization that may compromise depth perception and limit the surgeon’s ability to discern fine anatomical details [27, 31]. It is worth noting that the longest follow-up period in the included studies was 2 years postoperatively, and it is difficult to assess the true long-term recurrence rate. Therefore, the benefit of rVHR should be accurately evaluated.

Recent meta analysis on robotic-assisted laparoscopic incisional hernia repair have consistently shown a persistent cost disparity between rVHR and lapVHR [32]. In addition, rVHR has a longer learning curve, is difficult to popularize, and has a small audience, which is also an urgent problem to be solved. Future attention should focus on how to reduce the costs of rVHR. In the five included studies, we observed a high I² value ( I² = 75.8%) in operative Time, which indicates significant heterogeneity among the studies.It shows that there are significant differences among various studies in terms of surgeon experience, case complexity, and technical details. After appropriate training, there is a possibility that the operation time of the rVHR can be further shortened. The “time cost” of rVHR in complex cases may be offset by its precision advantage, especially in scenarios where fine adhesion release is required.Although the included literature is consistent in the fixation method of the patch and the size of the patch, however differences in the operator’s experience can also lead to heterogeneity. The studies of Käkelä et al. and Petro et al. did not clarify the training process of the surgeons and whether the surgical procedures were performed by the same team. In addition, the relatively small sample size also generated heterogeneity.

Limitations

This review synthesizes the available literature up to 2024, offering a comprehensive overview of current evidence and emerging trends in robot-assisted abdominal wall hernia repair. While it serves as a useful resource for consolidating existing knowledge, several limitations should be acknowledged. First, the relatively small number of included studies and their varying methodological quality underscore the need for more robust clinical investigations in this field. Additionally, the analysis does not address key technical comparisons, such as 2D versus 3D laparoscopic approaches, nor does it explore anatomical-specific considerations for optimal mesh selection—important factors that warrant further investigation. In addition, for indicators such as postoperative pain and quality of life, due to the small number of reports, it is difficult to perform a combined analysis, and it is impossible to further explore the benefits of patients. These could be further detailed and explored in future studies.

It is worth noting that rVHR shows superior results in terms of recurrence rate and re-hernia repair rate, but its cost impact warrants careful consideration. Although rVHR may require a higher initial investment in robotic systems and maintenance costs, it may lead to long-term cost savings by reducing recurrence rates and related reoperations. In addition, the improved precision and reduced complications of rVHR may result in shorter hospital stays and faster recovery times, further improving overall cost-effectiveness. However, the cost-effectiveness of rVHR may vary depending on factors such as hospital resources, surgical volume, and patient population. Future research should focus on conducting comprehensive cost-effectiveness analyses to better understand the economic impact of rVHR compared to traditional laparoscopic methods.

The GRADE assessments highlight the need for caution in applying these results to clinical practice. While rVHR appears to have advantages in certain outcomes, the varying levels of evidence certainty must be acknowledged. Due to the small sample size and wide confidence interval, the GRADE assessment rated the recurrence situation as evidence of moderate certainty. This means that although the existing data indicate a trend of reduced recurrence rate with the use of rVHR, the evidence is not sufficient to draw a definite conclusion. Larger - sample - size studies are needed in the future to solidify these findings. High-quality research, particularly with larger sample sizes and more rigorous methodology, is needed to strengthen the evidence base and provide more definitive recommendations.

Conclusion

In conclusion, this systematic review and meta-analysis revealed that rVHR is generally comparable to lapVHR, indicating that both were effective and safe. However, rVHR demonstrates superior outcomes with lower recurrence and re-hernioplasty rates and reduced incidence of surgical site infections. More high-quality studies are warranted to validate the results of this study.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Junfeng LI interpreted the data, wrote the initial manuscript, and was involved in the data analysis; Junfeng LI. was responsible for collecting all relevant papers; Shihong LI was responsible for supervising the study. Lunwu WEIwas in charge of performing the proofreading for the data. Huiping LI contributed to the analysis.All authors have read and agreed to the published version of the manuscript.

Funding

This study was not funded.

Data availability

Data supporting the findings of this study are available from the corresponding author upon reasonable request. (806471699@qq.com).

Code availability

Code may be made available upon reasonable request.

Declarations

Conflict of interest

There are no conflicts of interest to declare.

Ethics approval

Not applicable.

Human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors. As this was a systematic review and meta-analysis of published studies. Informed consent Informed consent was not necessary.

Consent to participate

Not applicable.

Consent for publication

Not applicable.