ROBOTIC VENTRAL HERNIA REPAIR

REVIEW OF LITERATURE

INTRODUCTION

Ventral hernia is a common general surgical problem with significant health,

functional, quality-of-life and health economic consequences. Ventral hernias affect
around one-quarter of adults, and incisional hernias develop in 10–15 per cent of open
abdominal incisions. While the nature of the surgical problem has not changed for
decades, the way that the surgeon approaches ventral hernia repair (VHR) has evolved
dramatically. Adult ventral hernias are common1, and include epigastric, umbilical,
Spigelian, and incisional hernias. Incisional hernias develop after 10–15 per cent of
laparotomies, and the risk of recurrence increases with each subsequent repair. Over
60 per cent of ventral hernias are repaired using an open approach, although there has
been a nearly 45-fold increase in repairs using robotics technology over the past
decade.
Despite still being one of the commonest operations performed by surgeons, there
remains a lack of consensus regarding the recommended “gold standard” method of
VHR. Recent times have seen the development of a myriad of alternative surgical
techniques, such as robotic VHR (RVHR) and extended view totally extraperitoneal
hernia repair (eTEP).
The traditional open ventral hernia repair (OVHR) involves direct repair of the defect
through an incision. Open primary suture repair without mesh is typically performed
for small primary defects under 2 cm.For larger or incisional hernias, open mesh
repair is preferred to reinforce the abdominal wall and reduce recurrence.
Laparoscopic ventral hernia repair (LVHR) was first described in 1993 by LeBlanc
and Booth. Due to its minimally invasive nature, requiring smaller incisions and less
traumatic tissue handling, it is associated with reduced post-operative pain, recovery
time, hospital length of stay (LOS) and wound complications compared to OVHR.4
Recent times have seen further development of other LVHR techniques beyond intra-
peritoneal onlay/underlay mesh (IPOM/IPUM), such as eTEP and mini/less-open
sublay (MILOS) repair.

The history of robotic ventral hernia repair can be traced back to the development and
evolution of robotic surgery technology in general. Here's an overview of the key
milestones and trends in the history of robotic ventral hernia repair as documented in
the literature:
• Early Adoption of Robotic Surgery: Robotic surgery, initially developed for military
purposes, began to be explored for medical applications in the late 20th century. The
da Vinci Surgical System, introduced in the early 2000s, marked a significant
advancement in robotic-assisted surgery and laid the foundation for its use in various
surgical specialties, including hernia repair.
• Initial Applications in General Surgery: In the early 2000s, surgeons began to
explore the use of robotic technology for general surgical procedures, including
ventral hernia repair. Early studies focused on evaluating the feasibility, safety, and
potential advantages of robotic-assisted techniques compared to traditional open and
laparoscopic approaches.
• Advantages and Clinical Outcomes: Literature from the mid-2000s to the present
highlights several advantages of robotic ventral hernia repair, including improved
visualization, precision, and ergonomics for surgeons. Clinical studies have reported
favorable outcomes, including reduced rates of recurrence, shorter hospital stays, and
faster recovery times compared to conventional techniques.
• Technique Refinement and Innovations: Over time, surgeons have refined
techniques and developed innovations in robotic ventral hernia repair to optimize
outcomes and patient satisfaction. This includes advancements in mesh selection,
fixation methods, and surgical approaches tailored to individual patient characteristics
and hernia anatomy.
• Comparative Studies: The literature includes numerous comparative studies
evaluating the outcomes of robotic ventral hernia repair versus traditional open and
laparoscopic techniques. While some studies demonstrate comparable outcomes
between approaches, others suggest potential advantages of robotic surgery, such as
reduced postoperative pain, lower complication rates, and improved cosmesis.
• Cost-Effectiveness and Healthcare Economics: A growing body of literature
explores the cost-effectiveness and healthcare economics of robotic ventral hernia
repair. While robotic surgery may incur higher initial costs due to equipment and
training expenses, some studies suggest that it can lead to overall cost savings through
reduced postoperative complications, shorter hospital stays, and faster return to
normal activities for patients.

Robotic surgery is purported to offer improved dexterity, precision, three dimensional

optics, and surgeon ergonomics. Improved manoeuvrability and degrees-of-freedom
may facilitate repair of large or complex hernias requiring component separation
techniques (CRT), such as transversus abdominis release (TAR). Disadvantages
include increased costs, reduced accessibility and increased operative time compared
to other approaches.It is questionable whether the benefits are justified by the costs.
Despite a clinical problem that has not changed over recent times, new approaches are
rapidly becoming available to the surgeon and patient. An evidence-based review of
techniques is required to consolidate the current understanding of best practice, and to
facilitate informed decision-making.

Robotic surgery has garnered significant interest in recent years as it offers the
potential of enhanced dexterity, precision, three-dimensional optics, and surgeon
ergonomics.
Robotic posterior component separations provide all of the benefits of retromuscular
mesh repair via a minimally invasive approach, obviating a laparotomy. Early
experiences have demonstrated advantages such as decreased wound morbidity and a
shorter hospital stay, which may offset the cost of the robotic platform and longer
operative times . In particular, patients with a body mass index (BMI) >35 kg/m2
(often a relative contraindication to open reconstructions) may benefit from robotic
repair as well . The impetuses to adopt robotic hernia repair are several, but at least
one strong motive is the fear of complications related to intraperitoneal mesh, which
are poorly defined. Intraperitoneal mesh has been the widely accepted approach to
ventral hernia repair for decades. As this approach gained traction internationally,
several negative sequelae became apparent, including mesh infections, mesh erosions,
enteric fistulas to mesh, and significant intra-abdominal adhesions making
reoperations difficult. On the other hand, there are also complications associated with
robotic dissections, including complete division of the linea alba, transection of the
linea semilunaris, and intraparietal hernias related to posterior sheath disruption. The
rates of these complications are not clear, but the negative effects are significant.
These complications are not exclusive to robotic platforms and may also occur in
open posterior component separations; however, it may be more challenging for a
surgeon to correctly identify the planes and relevant anatomy robotically, particularly
when first performing robotic hernia repairs. Therefore, robotic component separation
techniques should be studied carefully and with as much guidance as possible to avoid
patient morbidity. This topic will discuss robotic operations that mirror an open
Rives-Stoppa retrorectus dissection and an open transversus abdominis release.
Additional open component separation techniques can be found elsewhere. The
techniques of robotic ventral hernia repair and robotic groin hernia repair are
discussed in another topic. ROBOTIC TAR Robotic transversus abdominis release
(TAR) offers a retromuscular-based repair utilizing a posterior component separation
while also providing the benefits of a minimally invasive approach . In this
transabdominal approach, a retrorectus dissection and TAR are performed robotically
on each side of the abdomen, with the contralateral dissection requiring separate
docking of the robot. Ultimately, the anterior fascial defect is closed, the posterior
rectus sheath is reapproximated in the midline, and a retromuscular mesh is placed
with significant mesh overlap. Indications — A robotic TAR is required to repair
ventral hernias between 7 and 15 cm wide or hernias <7 cm wide with a narrow rectus
complex (ie, the hernia width to rectus width ratio >2) . Wider hernia defects (eg, 15
to 20 cm) may be amenable to robotic repair, but the fascia may be difficult to close
with a running locking stitch robotically under insufflation. For hernia defects >7 cm,
typically robotic TAR is performed bilaterally. Less frequently, unilateral TAR is
performed in cases where the defect is off midline or has a lateral component on one
side. Unilateral TAR may also be performed to augment a robotic Rives-Stoppa repair
for hernias <7 cm in a patient with a narrow rectus complex (hernia to rectus width
ratio >2). (See 'Robotic Rives-Stoppa retrorectus dissection' below.) Hybrid robotic
TAR — In difficult cases where the anterior fascia is under significant tension or the
patient has a large hernia sac and/or associated scar that needs to be excised, a robotic
platform need not be entirely abandoned. In such cases, if the adhesiolysis and
retromuscular dissection can be achieved using the robot, the scar and hernia sac can
be excised, the mesh placed, and the anterior fascia closed through a laparotomy
incision much smaller than would typically be done for a traditional open repair.
Outcomes of robotic TAR — Compared with historical controls of open TAR, robotic
TAR has been associated with longer operative times but shorter length of stay, lower
overall and wound complication rates, and similar readmission rates. Likewise, the
hybrid robotic TAR approach also reduced length of stay and wound morbidity .
While such retrospective reviews are potentially prone to selection bias, an ongoing
randomized trial of open versus robotic TAR for hernias 7 to 15 cm wide will provide
high-level evidence . ROBOTIC RIVES-STOPPA RETRORECTUS DISSECTION
Those who standardized the transabdominal robotic transversus abdominis release
(TAR) technique recognized that for smaller hernia defects, typically <7 cm in the
presence of a wide rectus complex, a posterior component separation was typically
not necessary. For these patients, the preperitoneal or retrorectus space provided a
pocket for mesh placement with plenty of overlap. A robotic dissection of the
retrorectus space can be accomplished in two ways, transabdominal or extended
totally extraperitoneal (eTEP). The transabdominal approach, which allows for direct
visualization of the viscera, can be preferable if reduction of incarcerated hernia
contents is challenging, as in the case of a small defect with a voluminous hernia sac,
particularly with bowel involvement. Proponents of the extraperitoneal technique
suggest that it is favorable in the context of a multiply reoperative abdomen since
intra-abdominal adhesions do not need to be dealt with. That said, extreme care needs
to be taken during the retromuscular dissection as inadvertent bowel injury can occur
to the underlying viscera during dissection of the hernia sac or previous scars. The
eTEP approach is favored by many for primary and concomitant epigastric, umbilical,
or inguinal hernias. It is also favorable when intraperitoneal mesh is relatively
contraindicated, such as in patients with Crohn’s disease. Indications — Robotic
Rives-Stoppa retrorectus dissections are usually performed for hernias <7 cm wide
with a wide rectus complex (ie, when the hernia to rectus width ratio is <2) (algorithm
1). Transabdominal approach — In this transabdominal technique, the retrorectus
space is developed, the anterior fascial defect is closed, a retrorectus mesh is placed,
and the retrorectus space is closed, all from an intraperitoneal perspective . eTEP
approach — The robotic eTEP approach affords retromuscular mesh placement for
small- to medium-sized defects (typically <7 cm) without requiring intraperitoneal
access or adhesiolysis . In this approach, the retrorectus space is directly accessed and
the entire dissection stays extraperitoneal. Taking advantage of the underlying
peritoneum and preperitoneal fat that bridge the adjacent posterior rectus sheaths, the
contralateral retrorectus space is accessed by "crossing over" in the midline
preperitoneal space while keeping the linea alba and anterior rectus fascia intact. The
contralateral retrorectus space can then be matured and the contiguous hernia sac and
contents reduced. Any defect in the posterior sheath or contiguous hernia sac as well
as the anterior fascial defect can all be closed from the retrorectus position without
necessarily requiring intraperitoneal access . In cases where the posterior rectus sheath
is under tension, a unilateral TAR can be added to the contralateral retrorectus
dissection. The technical tradeoff of the eTEP technique is the blind reduction of the
hernia sac and its contents while crossing the midline, which can seem risky.
Certainly, any difficulty or concern for a visceral injury can be mitigated by either
opening the hernia sac itself or by placement of intraperitoneal ports on the
contralateral side to safely allow for visualization of the incarcerated contents and safe
reduction of the viscera from the abdominal wall . Robotic eTEP requires careful
planning to ensure sufficient working space in the ipsilateral retrorectus pocket; the
robot can be docked laterally, inferiorly, or superiorly, depending on the location of
the hernia and the width of the rectus muscle. Typically a rectus of at least 6 cm wide
is necessary for the lateral dock approach, which is used for hernias in the European
Hernia Society (EHS) medial zone 2 (epigastric), 3 (umbilical), or 4 (infraumbilical)
regions (figure 2). Narrower rectus complexes or zone 5 (suprapubic) hernias require
superior docking, while zone 1 (subxiphoid) hernias require inferior docking . If the
rectus space is wide enough to allow for a lateral eTEP dock but the ratio of the hernia
to rectus width ratio is >2, then the need for a unilaterally robotic TAR on the
contralateral dissection should be anticipated. This is required approximately 10 to 22
percent of the time to relieve tension on the posterior rectus sheath closure . A robotic
TAR can be accomplished with the eTEP as well as the transabdominal approach.
Alternative techniques are required for subxiphoid hernias, suprapubic hernias, or
when the ipsilateral retrorectus space is insufficient to provide adequate working
space (<6 cm). Operative steps: Inferior dock — For isolated subxiphoid and
paraumbilical hernias, the retrorectus space is accessed in the same fashion, and the
midline crossover to the contralateral retrorectus space is done laparoscopically well
below the hernia defect. Once enough space is made in both retrorectus spaces,
robotic ports can be placed to perform the rest of the retromuscular dissection facing
cephalad. Operative steps: Superior dock — Likewise, for lower midline and
suprapubic defects or when the ipsilateral retrorectus space is not wide enough to
accommodate a side dock (<6 cm), the superior dock can be utilized by performing
the superior crossover laparoscopically to the contralateral retrorectus space. Next, the
robotic ports are placed cephalad, and the dissection is completed facing caudad.
Outcomes — Hernias <7 cm that are potential eTEP candidates would otherwise most
commonly be repaired by a minimally invasive intraperitoneal onlay mesh (IPOM).
Propensity score-matched comparison of robotic intraperitoneal mesh repairs with
eTEP repairs found that the eTEP approach was associated with fewer overall
complications and fewer wound complications. Other retrospective series reported
less pain for eTEP patients compared with intraperitoneal mesh repairs in the
postoperative period . However, in the REVEAL trial, which randomly assigned 100
patients to either robotic eTEP or robotic IPOM repair of midline ventral hernias ≤7
cm, there was no difference in pain at postoperative day 7 or 30 . Secondary outcomes
also showed similar results in regards to same-day discharge, postoperative quality of
life, and opioid consumption. Robotic IPOM did require less surgeon workload and a
shorter operative time (107 versus 165 minutes) and resulted in fewer postoperative
seromas than robotic eTEP repair. The cost saving of eTEP associated with less
expensive mesh utilization was therefore offset by the longer operative time. Even if
eTEP repairs offer no benefit with regard to patient-reported outcomes or recurrence,
some surgeons would favor extraperitoneal mesh to avoid the rare but devastating late
mesh complication that can occur many years after intraperitoneal placement . That
said, the risk of long-term complications from intraperitoneal mesh must also be
weighed against the risks associated with achieving extraperitoneal mesh placement,
such as posterior sheath or peritoneal breakdown, or inappropriate dissection of the
abdominal wall. During robotic intraperitoneal onlay mesh placement repair, the mesh
is commonly fixated using a running suture. Alternatively, for laparoscopic repair,
four cardinal sutures are commonly used, along with tacks in a single or double
crown. We chose the most common surgical techniques endorsed by major surgical
societies and acknowledge that some of the findings (operating room duration, patient
centered outcomes) observed in our trial may be related to different fixation
techniques. Multiple small randomized controlled trials have assessed mesh fixation
in laparoscopic repair, resulting in systematic reviews showing conflicting results.
When only studies at low risk of bias (that is, well performed randomized controlled
trials) have been evaluated, no differences among the different mesh fixation methods
has been clearly shown, except that fibrin glue fixation alone may increase hernia
recurrence rates.Proponents of RVHR quote improved patient centered outcomes
through a decrease in pain secondary to suturing rather than tacking of the mesh. 

Studies indicate that RVHR is associated with significantly shorter hospital LOS
compared to OVHR, but it is not significantly different from LVHR. Through reduced
trauma and incision size, MIS is associated with reduced postoperative pain, which is
a major factor in LOS.Moreover, intraoperative complications would be expected to
prolong LOS as they may require monitoring or treatment. Indeed, studies
demonstrated that intraoperative complication rate was significantly lower in RVHR
than OVHR, but comparable between RVHR and LVHR.

DISCUSSION

Studies demonstrated that robotic retrorectus VHR had significantly shorter LOS than
laparoscopic IPOM.Retrorectus mesh placement is technically challenging to achieve
in LVHR due to limited degrees of freedom.RVHR facilitates dissection of the
retromuscular space for mesh placement, which is thought to reduce the risks of
delayed complications such as adhesions, fistula formation and bowel injury,
compared with intraperitoneal mesh.The laparoscopic eTEP technique facilitates
wider dissection for retrorectus mesh placement. A systematic review by Li et al.
(2022) suggested robotic eTEP was associated with reduced LOS, however no
significant difference was found in intraoperative and postoperative complications.
Recurrence in hernia surgery is an important outcome as it affects quality of life and
may require re-operation. The assessment of recurrence in RVHR is limited, as most
available studies have follow-up periods of under 1 year.

Morbidity rates associated with open repair are high owing to patient factors and
hernia complexity, with short-term complication rates of up to 40 per cent5.
Laparoscopic repair has been recommended for large epigastric or umbilical hernias
by the European and Americas Hernia Societies6, largely on the basis of decreased
wound morbidity. Robotic surgery augments the laparoscopic approach with its
magnified three-dimensional visualization of the operative field, stable platform, and
superior range of motion7 that may be particularly beneficial for complex hernias.

In complex hernia surgery and abdominal wall reconstruction, OVHR remains the
standard approach for most surgeons. CRT, such as TAR, are useful in large complex
hernia repair as the mobilization of muscle and fascial layers helps to achieve tension-
free closure of the hernia defect and improved abdominal wall function following loss
of domain.CRT are seldom conducted laparoscopically due to ergonomic
limitations.54 RVHR offers benefits of MIS, while improving access to planes that
would otherwise be restricted in LVHR. The sub-analyses comparing R-TAR and O-
TAR indicate that R-TAR is associated with reduced LOS and 30-day readmission
rate, at the expense of longer operative time. Intra-operative and wound complications
were not significantly different between approaches. However, sub-analyses were
limited by the low number of studies available, with under 10 studies evaluating the
role of robotic surgery in VHR involving TAR. Future studies could further delineate
the role of robotic surgery in large, complex hernia repair and abdominal wall
reconstruction.

One Multicenter randomized controlled trial was performed by oscar A olivvaria et al

comparing both clinical and patient centered outcomes between RVHR and LVHR.
No evidence of a difference in length of stay was found between the groups.
However, RVHR needed nearly twice as much operative time and increased costs to
the healthcare system (even without accounting for the elevated acquisition costs of
the robotic platform and equipment estimated at $0.5-2.5m per platform and
maintenance costs estimated at $80 000-190 000 per platform per year). It was found
that no clinical, patient centered, or economic benefit to RVHR compared with
LVHR. The results of this study are in line with most other comparative studies
published from large datasets comparing RVHR and LVHR: no clinical benefit, with
increased operative duration and healthcare costs. This study unexpectedly found
more enterotomies with RVHR (3% v 0% with LVRH).

This outcome was not pre-specified (it was unexpected), was not statistically
significant, and could be due to chance or a true finding. Furthermore, a previous
study from the Americas Hernia Society database showed that RVHR was associated
with shorter length of stay in hospital by one day (0 days for RVHR versus 1 day for
LVHR; P≤0.001). Posterior component separation operations are unique in that they
have robotic adaptations but no well-established laparoscopic equivalent. That is
because they require precise dissection and intracorporeal suturing at difficult angles,
which is feasible robotically with wristed instrumentation but technically challenging
for most surgeons using traditional fixed laparoscopy .

A randomised control trial by clayton c petro et al

Seventy-five patients completed their minimally invasive hernia repair: 36
laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were
comparable. Robotic operations had a longer median operative time (146 vs 94
minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness
enterotomies or unplanned reoperations. There were no significant differences in
NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically,
median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61).
Likewise, postoperative Patient-Reported Outcomes Measurement Information
System 3a and hernia-specific quality-of-life scores, as well as length of stay and
complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13
vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85;
P < .001). It concluded that Laparoscopic and robotic ventral hernia repair with
intraperitoneal mesh have comparable outcomes. The increased operative time and
proportional cost of the robotic approach are not offset by a measurable clinical
benefit.

CONCLUSION

Future Directions and Challenges: The literature highlights ongoing research and
future directions in robotic ventral hernia repair, including the development of
enhanced imaging modalities, robotic instrumentation, and patient selection criteria.
Challenges such as longer operative times, learning curves for surgeons, and access to
robotic technology in resource-limited settings are also areas of active investigation
and discussion.

In summary, the history of robotic ventral hernia repair reflects a dynamic evolution
driven by advancements in technology, surgical techniques, and clinical evidence.
While the field continues to evolve, ongoing research and innovation hold promise for
further optimizing outcomes and expanding the role of robotics in hernia
management.
REFERENCES

1. Bedewi MA, El-Sharkawy MS, Al Boukai AA, Al-Nakshabandi N. Prevalence

of adult paraumbilical hernia. Assessment by high-resolution sonography: a
hospital-based study. Hernia 2012; 16:59.
2. Cherla DV, Viso CP, Moses ML, et al. Clinical assessment, radiographic
imaging, and patient self-report for abdominal wall hernias. J Surg Res 2018;
227:28.
3. Sazhin A, Zolotukhin I, Seliverstov E, et al. Prevalence and risk factors for
abdominal wall hernia in the general Russian population. Hernia 2019; 23:1237.
4. LEVENSON SM, GEEVER EF, CROWLEY LV, et al. THE HEALING OF
RAT SKIN WOUNDS. Ann Surg 1965; 161:293.
5. Schlosser KA, Renshaw SM, Tamer RM, et al. Ventral hernia repair: an
increasing burden affecting abdominal core health. Hernia 2023; 27:415.
6. Schluender S, Conrad J, Divino CM, Gurland B. Robot-assisted laparoscopic
repair of ventral hernia with intracorporeal suturing. Surg Endosc 2003; 17:1391.
7. Allison N, Tieu K, Snyder B, et al. Technical feasibility of robot-assisted
ventral hernia repair. World J Surg 2012; 36:447.
8. Sheetz KH, Claflin J, Dimick JB. Trends in the Adoption of Robotic Surgery
for Common Surgical Procedures. JAMA Netw Open 2020; 3:e1918911.
9. Henriksen NA, Jensen KK, Muysoms F. Robot-assisted abdominal wall
surgery: a systematic review of the literature and meta-analysis. Hernia 2019;
23:17.
10. Belyansky I, Weltz AS, Sibia US, et al. The trend toward minimally invasive
complex abdominal wall reconstruction: is it worth it? Surg Endosc 2018;
32:1701.
11. Martin-Del-Campo LA, Weltz AS, Belyansky I, Novitsky YW. Comparative
analysis of perioperative outcomes of robotic versus open transversus abdominis
release. Surg Endosc 2018; 32:840.
12. Liang MK, Subramanian A, Awad SS. Laparoscopic transcutaneous closure of
central defects in laparoscopic incisional hernia repair. Surg Laparosc Endosc
Percutan Tech 2012; 22:e66.
13. Gupta V, Singh SP, Pandey A, Verma R. Study on the use of T-tube for
patients with persistent duodenal fistula: is it useful? World J Surg 2013;
37:2542.
14. Holihan JL, Askenasy EP, Greenberg JA, et al. Component Separation vs.
Bridged Repair for Large Ventral Hernias: A Multi-Institutional Risk-Adjusted
Comparison, Systematic Review, and Meta-Analysis. Surg Infect (Larchmt)
2016; 17:17.
15. Wennergren JE, Askenasy EP, Greenberg JA, et al. Laparoscopic ventral
hernia repair with primary fascial closure versus bridged repair: a risk-adjusted
comparative study. Surg Endosc 2016; 30:3231.
16. Ahonen-Siirtola M, Nevala T, Vironen J, et al. Laparoscopic versus hybrid
approach for treatment of incisional ventral hernia: a prospective randomized
multicenter study of 1-month follow-up results. Hernia 2018; 22:1015.
17. Ahonen-Siirtola M, Nevala T, Vironen J, et al. Laparoscopic versus hybrid
approach for treatment of incisional ventral hernia: a prospective randomised
multicentre study, 1-year results. Surg Endosc 2020; 34:88.
18. Bernardi K, Olavarria OA, Holihan JL, et al. Primary Fascial Closure During
Laparoscopic Ventral Hernia Repair Improves Patient Quality of Life: A
Multicenter, Blinded Randomized Controlled Trial. Ann Surg 2020; 271:434.
19. Altieri MS, Yang J, Xu J, et al. Outcomes after Robotic Ventral Hernia Repair:
A Study of 21,565 Patients in the State of New York. Am Surg 2018; 84:902.
20. Zayan NE, Meara MP, Schwartz JS, Narula VK. A direct comparison of
robotic and laparoscopic hernia repair: patient-reported outcomes and cost
analysis. Hernia 2019; 23:1115.
21. Criss CN, MacEachern MP, Matusko N, et al. The Impact of Corporate
Payments on Robotic Surgery Research: A Systematic Review. Ann Surg 2019;
269:389.
22. Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic
Surgery? JAMA 2019; 321:1971.
23. Holihan JL, Alawadi Z, Martindale RG, et al. Adverse Events after Ventral
Hernia Repair: The Vicious Cycle of Complications. J Am Coll Surg 2015;
221:478.
24. Holihan JL, Hannon C, Goodenough C, et al. Ventral Hernia Repair: A Meta-
Analysis of Randomized Controlled Trials. Surg Infect (Larchmt) 2017; 18:647.
25. Li J, Wang Y, Wu L. The Comparison of eTEP and IPOM in Ventral and
Incisional Hernia Repair: A Systematic Review and Meta-analysis. Surg
Laparosc Endosc Percutan Tech 2022; 32:252.
26. Petro CC, Montelione KC, Zolin SJ, et al. Robotic eTEP versus IPOM
evaluation: the REVEAL multicenter randomized clinical trial. Surg Endosc
2023; 37:2143.
27. Morrell ALG, Morrell A, Morrell-Junior AC, et al. Standardization and ten
essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair
of ventral hernias. Rev Col Bras Cir 2020; 47:e20202622.
28. Belyansky I, Reza Zahiri H, Sanford Z, et al. Early operative outcomes of
endoscopic (eTEP access) robotic-assisted retromuscular abdominal wall hernia
repair. Hernia 2018; 22:837.
29. Ye L, Childers CP, de Virgilio M, et al. Clinical outcomes and cost of robotic
ventral hernia repair: systematic review. BJS Open 2021; 5.
30. Olavarria OA, Bernardi K, Shah SK, et al. Robotic versus laparoscopic ventral
hernia repair: multicenter, blinded randomized controlled trial. BMJ 2020;
370:m2457.
31. Dhanani NH, Olavarria OA, Holihan JL, et al. Robotic Versus Laparoscopic
Ventral Hernia Repair: One-year Results From a Prospective, Multicenter,
Blinded Randomized Controlled Trial. Ann Surg 2021; 273:1076.
32. Petro CC, Zolin S, Krpata D, et al. Patient-Reported Outcomes of Robotic vs
Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh: The PROVE-IT
Randomized Clinical Trial. JAMA Surg 2021; 156:22.
33. Petro CC, Thomas JD, Tu C, et al. Robotic vs Laparoscopic Ventral Hernia
Repair with Intraperitoneal Mesh: 1-Year Exploratory Outcomes of the PROVE-
IT Randomized Clinical Trial. J Am Coll Surg 2022; 234:1160.
34. Costa TN, Abdalla RZ, Tustumi F, et al. Robotic-assisted compared with
laparoscopic incisional hernia repair following oncologic surgery: short- and
long-term outcomes of a randomized controlled trial. J Robot Surg 2023; 17:99.
35. Costa TN, Tustumi F, Ferros LSM, et al. ROBOTIC-ASSISTED VERSUS
LAPAROSCOPIC INCISIONAL HERNIA REPAIR: DIFFERENCES IN
 DIRECT COSTS FROM A BRAZILIAN PUBLIC INSTITUTE
PERSPECTIVE. Arq Bras Cir Dig 2023; 35:e1714.
36. van der Schatte Olivier RH, Van't Hullenaar CD, Ruurda JP, Broeders IA.
Ergonomics, user comfort, and performance in standard and robot-assisted
laparoscopic surgery. Surg Endosc 2009; 23:1365.
37. Sánchez A, Rodríguez O, Jara G, et al. Robot-assisted surgery and incisional
hernia: a comparative study of ergonomics in a training model. J Robot Surg
2018; 12:523.
38. Lee GI, Lee MR, Green I, et al. Surgeons' physical discomfort and symptoms
during robotic surgery: a comprehensive ergonomic survey study. Surg Endosc
2017; 31:1697.