Open, laparoscopic, and hernia repair: more options, more questions—author’s reply

Abstract

To the Editor We would like to thank Dr. S. Huerta [1] for his comments about our recent study [2]. We also wish to praise Dr. S. Huerta for his numerous contributions to the field of general surgery, and more specifically, inguinal herniorrhaphy. As our study demonstrated, the volume of robotic inguinal hernia repairs continues to increase considerably in the Veterans Affairs as more centers obtain robotic platforms and surgeons grow more comfortable with the technology. Yet, the question that remains is which of the three surgical approaches to inguinal hernia repair (open, laparoscopic, or robotic) is superior? Certainly, this is a complex issue, and unfortunately, a definitive answer was outside the scope of our study. While we demonstrated improvements in operative times and post-operative complication rates in the robotic inguinal hernia repair cohort, we were not able to assess metrics, such as recurrence or long-term inguinodynia. We concede that prospective, long-term data are needed in this topic to further explore this issue. While robotic inguinal hernia repair has grown in popularity, the role of open and laparoscopic techniques remains paramount for the practicing general surgeon. The laparoscopic and open approaches offer key advantages to the robotic platform that can optimize perioperative outcomes. Robotic inguinal hernia repair requires general anesthesia which carries the risk of cardiopulmonary complications as well as entry into the abdominal cavity, which promotes adhesions and injury to intraperitoneal viscera [3]. In contrast, the open approach may be performed safely with local anesthesia, and laparoscopic herniorrhaphy is performed regularly using a totally extraperitoneal approach [3]. Nevertheless, robotic inguinal hernia repair is relatively new compared to the other techniques and shows intriguing potential. Robotic inguinal hernia repair offers favorable patient-reported outcomes in terms of pain, resumption of daily activities of living, and return to work [4]. Furthermore, the role of robotics has been demonstrated in complex, bilateral, and recurrent inguinal hernia repairs [5]. With the multitude of operative approaches to the most common procedure performed in general surgery, more questions truly remain as Dr. S. Huerta has aptly phrased [1]. Randomized controlled trials with long-term follow-up likely comprise the ideal modality to discern the optimal surgical technique. Unfortunately, other factors remain at the crux of this issue including surgeon experience and comfort level, available institutional resources, and patient preference. At present, we concur with Dr. S. Huerta on laparoscopy as the gold standard for bilateral and recurrent groin hernia repair, and an open approach for unilateral inguinal hernia repair. But, as with all innovations in surgery, time will truly be the ultimate test to determine the role that robotic inguinal hernia repair serves in the armamentarium of the general surgeon.