Beldi, Guido

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INVITED COMMENTARYTechnical Feasibility of a Robotic-Assisted Ventral Hernia RepairGuido BeldiPublished online: 29 December 2011 Socie´te´ Internationale de Chirurgie 2011Incisional hernia is one of the most frequent complicationsafter abdominal surgery. Its incidence is typically under-estimated and may range up to 26% [1]. Thus, novel andpotent strategies to prevent and treat incisional hernia arerequired. Implantation of a prosthetic mesh has become the‘‘gold standard’’ of open and laparoscopic incisional herniarepair. Laparoscopic mesh implantation is associated withthe typical advances of laparoscopy, such as a lower rate ofsurgical site infections and reduced hospital stay [2, 3].However, hernia recurrence has not been reduced signifi-cantly by the laparoscopic approach and long-term painremains a therapeutic challenge in a subset of patients[4, 5].In this issue of the Journal, Allison and colleagues [6]explored a novel therapeutic strategy. By using the Da VinciRobot, the authors took advantage of facilitated intracor-poreal suturing. Thus, adaptation of the hernial orifice,which may be demanding during laparoscopic surgery, wasmastered using the robot. Because of the technical difficul-ties, this operative step is not performed during many lapa-roscopic incisional hernia repairs. Closing the hernial orificemay play an important role, because it reduces a gap in theabdominal wall, which in turn may result in migration of themesh by being pushed into this gap by elevated intra-abdominal pressure. Here, robotic surgery potentially facil-itates this step, which might be of importance to a lowerrecurrence rate.The authors also used the robot for mesh fixation usingrunning sutures and thereby avoiding the insertion oftransfascial sutures or metal tacks. Either of these fixationdevices, or combinations, is nowadays required for effec-tive mesh fixations but is associated with specific risks [5].Robotic surgery, however, is time-consuming and asso-ciated with increased costs. Until now, no significantadvances for general abdominal surgery have been shownand the robot failed to be introduced widely. But why? In ourown experience, we performed robotic surgery in 21 robot-assisted laparoscopic groin hernia repair (TAPP). The pro-cedure was technically feasible and helped to improve ourskills in the use of the robot. However, the advantages oflaparoscopic repair were not improved by the robot. Neithersafety nor morbidity was superior compared with retro-spective series. In particular, costs were increased by 34% byusing the robot.Similarly, in the present article [6], the authors describedthe feasibility and safety of robot-assisted incisional herniarepair. Some of the achievements have to be regarded withcaution, because the authors used the robot for rather smallhernias, which are typically not associated with elevated riskof recurrence and pain. Thus, it will be a long way to showany improvement of robot-assisted incisional hernia repaircompared with conventional laparoscopic procedures. Inparticular, the field of laparoscopic incisional hernia repair isstill moving forward and critical steps, such as fascial clo-sure, the perfect type of mesh, or the perfect fixation method,are currently being investigated. Thus, there is currently no‘‘gold standard’’ for the comparison with robotic repair,including open repair. The authors, or other investigators,will have to show an improvement by robotic incisionalhernia repair, e.g., lower recurrence rate or less pain, tojustify such expensive procedures. Furthermore, currentrobots have known disadvantages: notably the visualizationof large areas and working in different abdominal regions isstill difficult—both of which are required for laparoscopicventral hernia repair. Thus, robots need to be improvedG. Beldi (&)Department of Visceral Surgery and Medicine,Bern University Hospital, Bern, Switzerlande-mail: Guido.Beldi@insel.ch123World J Surg (2012) 36:453–454DOI 10.1007/s00268-011-1401-3significantly by introducing novel technologies to enable thesurgeon to benefit from its advantages and potentially allowits widespread use for incisional hernia repair.References1. Sorensen LT, Hemmingsen UB, Kirkeby LT et al (2005) Smokingis a risk factor for incisional hernia. Arch Surg 140:119–1232. Sauerland S, Walgenbach M, Habermalz B et al (2011) Laparo-scopic versus open surgical techniques for ventral or incisionalhernia repair. Cochrane Database Syst Rev CD0077813. Forbes SS, Eskicioglu C, McLeod RS et al (2009) Meta-analysis ofrandomized controlled trials comparing open and laparoscopicventral and incisional hernia repair with mesh. Br J Surg 96:851–8584. Sajid MS, Bokhari SA, Mallick AS et al (2009) Laparoscopicversus open repair of incisional/ventral hernia: a meta-analysis.Am J Surg 197:64–725. Beldi G, Wagner M, Bruegger LE et al (2011) Mesh shrinkage andpain in laparoscopic ventral hernia repair: a randomized clinicaltrial comparing suture versus tack mesh fixation. Surg Endosc25:749–7556. Allison et al (2011) Technical feasibility of a robotic assistedventral hernia repair. World J Surg (in press). doi:10.1007/s00268-011-1389-8454 World J Surg (2012) 36:453–454123

Technical Feasibility of a Robotic-Assisted Ventral Hernia Repair

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Technical Feasibility of a Robotic-Assisted Ventral Hernia Repair

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