Comparative perioperative outcomes of single-port laparoscopic ArtiSential versus da Vinci SP platform for totally extraperitoneal inguinal hernia repair: a multi-institutional, propensity score-matched analysis in Korea

Abstract

Purpose

This study aimed to compare perioperative and postoperative outcomes of single-port laparoscopic articulated instrument-assisted versus da Vinci SP-assisted totally extraperitoneal (TEP) inguinal hernia repair using a propensity score-matched multi-institutional cohort.

Methods

Between April 2022 and July 2025, 221 patients underwent TEP unilateral inguinal hernia repair at four institutions. Among them, 33 patients underwent da Vinci SP-assisted repair (Intuitive Surgical) and 188 underwent single-port laparoscopy using the articulated instrument, ArtiSential (LivsMed). Propensity score matching was performed in a 11 ratio based on demographic and clinical variables, resulting in 30 matched patients in each group. Perioperative outcomes and postoperative complications were analyzed.

Results

After matching, baseline characteristics were well balanced between the groups. Operative time was significantly longer in the da Vinci SP group than in the ArtiSential group (median [interquartile range], 82.0 [67.5–105.0] vs. 35.0 [28.5–47.5] minutes; p < 0.001). No open conversions occurred, and conversions to transabdominal preperitoneal repair were rare and comparable. Mesh size selection differed significantly, with smaller meshes more frequently used in the da Vinci SP group (p < 0.001). Postoperative outcomes, including length of hospital stay, overall complication rates, chronic pain, and recurrence, were similar between the groups. No major complications, readmissions, or reoperations were observed.

Conclusion

Articulated instrument-assisted TEP inguinal hernia repair demonstrated a significantly shorter operative time than da Vinci SP-assisted repair, while perioperative safety and postoperative outcomes were comparable.

INTRODUCTION

Minimally invasive surgery (MIS) has become the standard approach for inguinal hernia repair, and current guidelines from the European Hernia Society recommend laparoscopic techniques as the treatment of choice for primary unilateral, bilateral, and recurrent inguinal hernias following anterior repair [1]. Compared to open Lichtenstein repair, laparoscopic approaches have demonstrated advantages in terms of reduced postoperative pain, lower rates of wound-related complications, and faster return to normal activities [2–4].

To further minimize surgical invasiveness, single-incision laparoscopic surgery (SILS) has been introduced and applied to inguinal hernia repair, with favorable clinical and cosmetic outcomes. SILS is associated with reduced postoperative pain, improved patient satisfaction, and superior cosmetic results [5]. However, the widespread adoption of SILS remains limited because of technical challenges including restricted triangulation, external and internal instrument collisions, and ergonomic constraints, which require advanced technical expertise and may compromise operative efficiency [6,7].

To address these limitations, robotic platforms are increasingly used in inguinal hernia surgery. Robotic-assisted repair has been shown to be feasible and safe, with perioperative outcomes comparable to those of conventional laparoscopic repair. Nevertheless, previous studies and meta-analyses have reported longer operative times and higher costs associated with robotic approaches, particularly for unilateral inguinal hernia repairs [8–10]. Considering cost-effectiveness, a multi-joint laparoscopic instrument, ArtiSential (LivsMed Inc.) was developed, and its safety and effectiveness in colorectal surgery were demonstrated through comparative studies with conventional laparoscopy and robotic surgery [11,12].

Recently, the da Vinci Single Port (DVSP) surgical system (Intuitive Surgical) was introduced as a novel robotic platform designed to overcome some of the inherent limitations of both conventional laparoscopy and multiport robotic systems by enabling the deployment of multiple articulated instruments through a single access port [13,14]. Despite the expanding clinical applications of the DVSP system, evidence evaluating its role in inguinal hernia repair remains limited, especially in comparison with advanced articulated laparoscopic instruments [15,16]. Direct comparative studies assessing the perioperative and postoperative outcomes of DVSP- and articulated instrument-assisted single-port inguinal hernia repairs are scarce. Therefore, the present multi-institutional retrospective study aimed to compare surgical outcomes of DVSP-assisted and single-port laparoscopic ArtiSential-assisted surgery for unilateral inguinal hernia, focusing on operative efficiency, safety, and short-term postoperative outcomes.

METHODS

We retrospectively reviewed 221 patients who underwent single-port totally extraperitoneal (TEP) inguinal hernia repair in the Department of Surgery of Hansol Hospital, Seoul St. Mary’s Hospital, Incheon St. Mary’s Hospital, and St. Vincent’s Hospital between April 2022 and July 2025. The patients were divided into the ArtiSential and DVSP groups. A 1:1 propensity score matching (PSM) analysis was performed using the history of previous prostate surgery, body mass index (BMI), American Society of Anesthesiologists physical status (ASA PS) classification, sex, and location of the inguinal hernia.

Inguinal hernia was diagnosed based on clinical evaluation (history and physical examination), ultrasonography, or abdominal computed tomography. Patient inclusion criteria included the following: age ≥18 years, admission in the surgery department, ASA PS classes I to III, and cases of only inguinal hernia (direct, indirect, or mixed). The exclusion criteria were as follows: age <18 years and emergency repair for outlet obstruction or strangulation. The patients returned to the outpatient department seven days after discharge to evaluate their general condition.

The primary outcome was operative time. The secondary outcomes included conversion to other methods, complications, hospital stay, and postoperative analgesic medication. Mesh size and hernia type were also analyzed.

Surgical procedure

Da Vinci single-port robotic totally extraperitoneal

Under general anesthesia, patients were placed in a supine position with gentle flexion. After sterile skin preparation, an infraumbilical incision of approximately 2.5 cm was performed and dissected above the anterior rectus fascia. A vertical incision was made on the anterior rectus fascia to the ipsilateral side of the hernia, and the hernia was gently dissected into the retrorectus space using an S-shaped retractor. A single-port access device was inserted into the retrorectus space, and a 12-mm port of this device was used at the single-port robotic multichannel port. After docking, the camera was positioned above, and fenestrated bipolar forceps were used via the left arm. Curved monopolar scissors were used via the right arm. To enter the narrow extraperitoneal space, the retrorectal space was created by slowly moving the bilateral instrument and camera. The subsequent procedure was the same as the laparoscopic TEP procedure: locating the hernia sac, performing high ligation with a surgical loop, and applying a mesh. The mesh was applied using surgical glue, the robotic instruments were removed, and the extraperitoneal space was degassed to confirm that the mesh was well spread (Fig. 1B, D). This procedure was performed as previously described [17,18].

Fig. 1.

Surgical techniques for single-port totally extraperitoneal (TEP) inguinal hernia repair. (A, C) ArtiSential (LivsMed Inc.) articulated laparoscopic instrument-assisted TEP repair showing the multi-joint instruments in the retrorectus and extraperitoneal spaces during hernia sac manipulation and mesh placement. (B, D) Da Vinci SP (Intuitive Surgical) robotic system-assisted TEP repair demonstrating the robotic instruments deployed through a single port in the retrorectus space (left arm with fenestrated bipolar forceps, right arm with monopolar curved scissors).

Laparoscopic single-port totally extraperitoneal using ArtiSential instrument

Under general anesthesia, the patient’s position was maintained the same as that used for robotic surgery. A 2-cm incision was made in the infraumbilicus, and a single-port access was inserted into the retrorectal space in a similar manner. The surgeon and scopist stood side-by-side on opposite sides of the hernia and inserted a camera and articulated instruments. The left arm of the surgeon was equipped with an articulated grasper, whereas the right arm was alternately fitted with an articulated spatula (Fig. 1A, C). The extraperitoneal space was created, the hernial sac was located, high ligation of the sac was performed, and a mesh was applied in a manner similar to that of robotic surgery. Related journals have published detailed technical tips and videos [19,20].

Statistical analyses

Continuous variables are expressed as mean ± standard deviation, and categorical variables are expressed as numbers (%). Differences between groups were evaluated using a Student t-test and chi-square test for continuous and categorical variables, respectively. PSM was performed to minimize selection bias and control for confounding factors. To calculate the individual scores, a non-parsimonious logistic regression model was used in accordance with predefined covariates, including previous prostate surgery, BMI, ASA PS class, sex, and hernia location. Patients who underwent single-port TEP inguinal hernia repair were matched based on scores from the nearest neighbor algorithm and 1:1 matching without a specific caliper width or replacement. Statistical analysis was performed using IBM SPSS version 24.0 (IBM Corp.). Statistical significance was set at p < 0.05.

RESULTS

After PSM, 30 patients were included in each group. Baseline demographic and clinical characteristics were well balanced between the DVSP and ArtiSential groups (Table 1). There were no significant differences between the two groups in terms of age, sex distribution, BMI, ASA PS classification, hernia laterality, smoking status, or comorbidities including hypertension, diabetes mellitus, and benign prostatic hyperplasia. The proportion of recurrent hernias was identical in both groups (DVSP, 1 [3.3%] vs. ArtiSential, 1 [3.3%], p > 0.999).

Table 1.

Baseline characteristics of patients stratified by operation type

Characteristic	Before propensity score matching					After propensity score matching
	Da Vinci SP	Articulated instrument	p-value	SMD		Da Vinci SP	Articulated instrument	p-value	SMD
No. of patients	33	188				30	30
Age (yr)	54.8 ± 14.5	56.9 ± 16.7	0.470	0.15		54.2 ± 14.6	54.4 ± 16.7	0.961	0.01
Male sex	26 (78.8)	177 (94.1)	0.008	0.46		23 (76.7)	23 (76.7)	>0.999	0.00
Body mass index (kg/m2)	24.1 ± 3.75	23.6 ± 2.41	0.455	0.15		24.3 ± 3.9	23.3 ± 2.3	0.230	0.29
Hernia location (right/left)	18/15	115/73	0.002	0.39		16/14	16/14	>0.999	0.00
ASA PS classification, I/II/III	14/16/3	79/104/5	0.178	0.16		12/15/3	12/15/3	>0.999	0.00
History of prostate cancer surgery	0 (0)	11 (5.9)	0.377	0.31		0 (0)	0 (0)	-	-
Recurrent hernia	1 (3.0)	7 (3.7)	>0.999	0.03		1 (3.3)	1 (3.3)	>0.999	0.00
Smoking	1 (3.0)	24 (12.8)	0.138	0.32		1 (3.3)	4 (13.3)	0.353	0.27
Benign prostate hyperplasia	4 (12.1)	20 (10.6)	0.764	0.05		4 (13.3)	2 (6.7)	0.389	0.21
Hypertension	14 (42.4)	59 (31.4)	0.214	0.23		12 (40.0)	11 (36.7)	0.791	0.07
Diabetes mellitus	2 (6.1)	10 (5.3)	0.696	0.17		2 (6.7)	3 (10.0)	0.640	0.12

Values are presented as number only, mean ± standard deviation, or number (%).

SMD, standardized mean difference; ASA, American Society of Anesthesiologists; PS, physical status. da Vinci SP, Intuitive Surgical; ArtiSential, LivsMed.

The intraoperative outcomes are summarized in Table 2. Operative time was significantly longer in the DVSP group than in the ArtiSential group (median [interquartile range], 82.0 minutes [67.5–105.0] vs. 35.0 [28.5–47.5] minutes; p < 0.001). No conversions to open surgery were observed in either group. One patient (3.3%) in the DVSP group and none in the ArtiSential group (p = 0.321) converted to transabdominal preperitoneal repair. Mesh size selection differed significantly between the two groups, with smaller meshes being more frequently used in the DVSP group than in the ArtiSential group (p < 0.001). The distribution of hernia types and postoperative α-blocker use did not differ significantly between groups.

Table 2.

Intraoperative and postoperative outcomes

Variable	Before propensity score matching				After propensity score matching
	Da Vinci SP (n = 33)	Articulated instrument (n = 188)	p-value		Da Vinci SP (n = 30)	Articulated instrument (n = 30)	p-value
Operation time (min)	92.0 (71.0–105.0)	40.0 (30.0–50.0)	<0.001		82.0 (67.5–105.0)	35.0 (28.5–47.5)	<0.001
Open conversion	0 (0)	0 (0)	-		0 (0)	0 (0)	-
TAPP conversion	1 (3.0)	0 (0)	0.176		1 (3.3)	0 (0)	0.321
Mesh size (cm), 15 × 10/13 × 9	15/18	186/2	<0.001		13/17	30/0	<0.001
Hernia type, direct/indirect/femoral/pantaloon	7/23/1/2	21/160/0/7	0.030		5/23/1/1	3/27/0/0	0.420
Postoperative alpha-blocker use	0 (0)	15 (8.0)	0.136		0 (0)	2 (6.7)	0.492

Values are presented as median (interquartile range) or number (%).

TAPP, transabdominal preperitoneal repair. da Vinci SP, Intuitive Surgical; ArtiSential, LivsMed.

Statistical significance was set at p < 0.05.

The postoperative outcomes and complications are presented in Table 3. The length of postoperative hospital stay was comparable between the two groups (1.0 ± 0.64 days vs. 1.0 ± 0.26 days, p > 0.999). The overall complication rates were identical (6.7% in each group, p > 0.999), and no patient required readmission or reoperation. Minor complications, including seroma and skin bleeding, occurred infrequently and were distributed similarly between the groups. No major complications (Clavien-Dindo grade III or higher) were observed. The incidences of chronic pain and hernia recurrence did not differ significantly between the groups during follow-up (median 6 [6-7] months).

Table 3.

Comparisons of postoperative outcomes and complications in the propensity score-matched sample

Variable	Da Vinci SP (n = 30)	Articulated instrument (n = 30)	p-value
Length of hospital stay	1.0 ± 0.64	1.0 ± 0.26	>0.999
Overall complication	2 (6.7)	2 (6.7)	>0.999
Seroma	1 (3.3)	1 (3.3)	>0.999
Skin bleeding	0 (0)	1 (3.3)	0.313
Urinary retention	0 (0)	0 (0)	-
Chronic paina)	1 (3.3)	0 (0)	0.305
Complication b), Clavien-Dindo classification
I–II	2 (6.7)	2 (6.7)	>0.999
III–IV	0 (0)	0 (0)	-
Readmission within 30 days after surgery	0 (0)	0 (0)	-
Reoperation within 30 days after surgery	0 (0)	0 (0)	-
Recurrence during study period	1 (3.3)	0 (0)	0.313

Values are presented as mean ± standard deviation or number (%).

da Vinci SP, Intuitive Surgical; ArtiSential, LivsMed.

^a)Chronic pain was defined as pain persisting beyond 3 months postoperatively. ^b)No major complications (grade III–IV) or reoperations were observed in either group during the follow-up period.

DISCUSSION

MIS for inguinal hernia repair has been widely adopted owing to its advantages of reduced postoperative pain, faster recovery, and improved cosmetic outcomes compared with open repair [2,21]. To maximize these benefits, various approaches utilizing fewer ports or single incisions have been introduced [22]. However, reduced- or single-port surgery is technically demanding because of limited triangulation, instrument collision, and difficulty in achieving adequate traction and countertraction, particularly in confined spaces, such as the preperitoneal plane [23].

Robotic surgical systems have been developed to overcome some technical limitations of conventional laparoscopy. The DVSP system represents a further evolution, featuring a single robotic arm that deploys a flexible camera and three multi-jointed instruments through a single port, thereby potentially reducing external arm collisions and improving intracorporeal dexterity [24,25]. Despite these theoretical advantages, evidence on the clinical benefits of single-port robotic systems for inguinal hernia repair remains limited.

In this multi-institutional study, we compared articulated instrument- and DVSP-assisted TEP inguinal hernia repair using a propensity score-matched cohort. After matching, perioperative safety and postoperative outcomes were comparable between the two groups. Notably, no open conversions, major complications, readmissions, or reoperations were observed in either group, suggesting that both approaches are safe and feasible when performed by experienced surgeons.

However, the operative time was significantly longer in the DVSP group than in the articulated instrument group. This can be attributed to several factors. First, the single-port robotic platform requires additional steps related to docking, arm deployment, and adjustment of the internal articulation, which may prolong the operative time, particularly during the early learning phase. Second, although the single-port system allows multiple instruments to be delivered through a single arm, the relatively bulky and heavy nature of the robotic arm may limit maneuverability in the preperitoneal space compared to lightweight articulated laparoscopic instruments. These results are consistent with previous reports that demonstrated longer operative times during the initial adoption phase of new robotic platforms.

An interesting finding of this study was the significant difference in mesh size selection between groups, with smaller meshes more frequently used in the DVSP group. This may reflect differences in working space perception or surgeon preference when operating with the single-port platform as well as constraints related to mesh handling and deployment through a single-port system. Despite this difference, no increase in recurrence or postoperative complications was observed during the follow-up period, suggesting that appropriate mesh placement can be achieved using either approach.

Although the DVSP system offers potential advantages, including improved cosmesis and reduced external arm collisions, several limitations should be acknowledged. Similar to previous reports, the grasping force of the single-port instruments may be inferior to that of conventional robotic or articulated laparoscopic instruments, which could pose challenges for patients with dense adhesions, large hernia sacs, or obesity. Furthermore, effective use of the single-port platform requires a skilled assistant to provide suction, additional traction, and instrument exchange through the assistant port.

This study had several limitations. First, the retrospective design and relatively small matched sample size may have limited the generalizability of the findings and the statistical power to detect the observed 40-minute difference in operative time; the study is substantially underpowered to detect differences in low-frequency outcomes such as hernia recurrence, chronic pain, and major complications. Statements suggesting equivalence or comparable safety between groups for low-frequency outcomes should therefore be interpreted very cautiously, and the possibility of Type II error must be explicitly acknowledged. Larger prospective studies with increased sample sizes and longer follow-up periods will be necessary to definitively establish whether these surgical approaches differ in rates of recurrence, chronic pain, or major complications. Second, this study predominantly included cases of relatively low surgical complexity, with most patients having primary unilateral hernias without significant comorbidities; only 3.3% of each group had recurrent hernias, and we excluded emergency cases and highly complex presentations. The findings may not generalize to more complex hernia repairs (bilateral, recurrent, or with challenging anatomy), where operative time and technical difficulty considerations may differ substantially. Third, this represents an early adoption cohort for the da Vinci SP platform, with limited surgeon experience (8–12 months) and small institutional case volumes (20–35 cases per center); the operative time advantage for articulated instruments may not persist as robotic platform experience matures and surgeon familiarity improves. Finally, a cost analysis was not performed and a comprehensive health economic analysis comparing equipment acquisition costs, maintenance expenses, operative time productivity, and training requirements would strengthen clinical decision-making and is recommended for future studies.

In conclusion, articulated instrument-assisted TEP inguinal hernia repair demonstrated a significantly shorter operative time than DVSP-assisted repair, although perioperative safety and postoperative outcomes were comparable. The DVSP system is a feasible and safe option for TEP repair; however, its routine use should be weighed against operative efficiency, cost, and case complexity. Further prospective studies with larger cohorts and longer follow-up periods are warranted to better define the role of single-port robotic systems in inguinal hernia surgery.