Hernia | 2021
Open, laparoscopic, and robotic inguinal hernia repair: more options, more questions
Abstract
To the Editor In the manuscript: “trends and outcomes of open, laparoscopic, and robotic inguinal hernia repair in the veterans affairs system” by Holleran et al. [1], the authors have shown, in a large nationwide data base (VASQIP), a substantial increase in the use of robotics for inguinal hernia repair from 0.24 to 19.6% between 2008 and 2019. Notably, this was accompanied by a considerable decrease in complications from 20.8 to 3.5%, as well as operative times from 4.9 ± 1.6 h versus 2.8 ± 1.6 h during the same period. Given the trends, it is likely that the number of cases for robotic inguinal hernias will continue to increase. However, the rate of complications and operative times might be variable. For open inguinal hernia repairs at VA hospitals, it has been my experience that these cases allow a more substantial involvement of junior house staff. For instance, of the 100,880 open hernia repairs reported in this manuscript, 1233 originate from my personal experience at the Dallas VA during the study period [2]. I performed most of these cases (84.2%) with junior residents (PGY-1 to PGY-3). In some cases (~ 2.0%), I have only supervised a senior resident taking a junior resident through the operation. Currently, this is not the case with the robotic approach as faculty and senior residents are involved with most operations. Thus, as comfort with the robotic platform increases so will junior resident participation, which leaves outcomes and operative room times to be re-analyzed. I congratulate the authors for a well-written manuscript and the comprehensive review of the literature on this matter. Additionally, they have done a good job outlining the limitations of analyzing a national large database, which among many include the lack of granularity. For instance, I would have liked to see the types of hernias that were repaired for each approach (i.e., share of hernias that were recurrent, bilateral, femoral, etc.). Importantly, as the authors indicated, recurrence and inguinodynia remain an important aspect of outcomes for groin hernia repair. The authors have also emphasized the ability to undertake the open repair with local anesthesia, which has been shown to result in a decrease in complications, operative time, and cost especially in the elderly [3–5]. In a prior discussion with Aiolfi et al. regarding this issue [6], I agree that a patient-tailored approach for inguinal hernia repair is important and centers of excellence for inguinal hernia repair should have all options available. Surgeons can present the data to patients who might have specific preferences. However, as of today, laparoscopic inguinal hernia repair remains the preferred approach for bilateral and recurrent groin hernias. The open approach remains the gold standard for unilateral groin hernia repair [7].