Reasons to Avoid Robotic Surgery for Most Inguinal Hernias – Debunking the “Minimally Invasive” Myth

Published: April 2025

 

You’ve probably heard about robotic surgery, but do you really understand what it is? You may have heard that robotic surgery is minimally invasive and more advanced than open surgery; however, despite widespread marketing efforts, this rhetoric couldn’t be further from the truth when it comes to inguinal hernia surgery. 

Robotic surgery was first performed in the late 1980s for hip replacements1. Since then, it has expanded tremendously with technological advancements and increased market competition. Today, robotic surgery involves a surgeon controlling a machine with different arms. One arm holds a camera and other arms hold tools. Each of these instruments enter the body through small incisions and the surgeon controls each instrument while sitting at a console next to the patient.  

While robotic surgery may be a superior approach in certain circumstances, routine inguinal hernia surgery is not one of them – at least, it shouldn’t be. Certain open repairs, such as the open preperitoneal mesh repair, are less invasive, less expensive, and carry less risk of complications when performed by skilled specialists2,3. The open preperitoneal mesh repair results in the exact same end result – mesh is placed in the same location – but the approach to getting it there is much more direct, and doesn’t require surgeons to get into the abdominal cavity at all. This reduces the overall impact the surgery has on your body and comes with far less risk. Continue reading to learn more about the risks, benefits, alternatives, and what to know when choosing a hernia surgeon.

 

What are the risks of robotic hernia surgery?

  • General Anesthesia
    • General anesthesia involves several medications, including some that cause paralysis of muscles. This is needed to allow the abdominal cavity to be inflated with a gas that is necessary to perform robotic surgery, otherwise your muscles wouldn’t allow this to happen. These medications also affect other muscles in the body like those used to breathe. For this reason, a breathing tube is placed and a ventilator is used to breathe for you.  A “Foley” bladder catheter may also be required. This collection of medications required for general anesthesia result in a longer period of time to wake up and comes with more grogginess in the process. While general anesthesia is very safe and is an important part of many more invasive surgeries, it is harder on the body, and should only be used when necessary4,5.
  • Multiple Incisions
    • In order to insert the robotic probes, 3-4 incisions are usually made in the upper abdomen. Each incision carries risk, including the possibility of developing incisional hernias down the line. These incisions allow access to the abdominal cavity which is inflated with a gas to create space to work in during the surgery. 
  • Injury to Surrounding Tissues
    • Since the surgeon uses a control panel to direct the robotic probes and instruments, personal tactile feedback is removed. Imagine pulling on paper towel and feeling the paper get tighter as the tension increases in your fingers. As you keep pulling, you are getting feedback that that paper is about to tear. When the surgeon sits at a console and is separated from actually holding or touching the tissues, this feedback is lost. They cannot feel increased tension but instead have to visualize it and hope they are reading visual clues right. This carries an increased risk of tissue damage and post-operative issues.
    • Most of the time, the protective sac around the intestine, called the peritoneum, is cut in order to do robotic surgery. As discussed, these surgeries are usually performed within the abdominal cavity – in the same space as these organs. Sharing this space increases the chance of an intestinal complication during or after surgery.
    • General surgeons, not high-volume hernia specialists, perform most robotic inguinal hernia surgeries. Lack of specialization means less expertise and potentially higher complication rates. We know that surgeons who do more of one type of surgery, produce better outcomes for their patients6. Hernia specialists at our practice perform 10x the hernia repairs that a general surgeon does in a year. 
  • Financial Burden
    • Robots are expensive! And so are the individual instruments that are required in these surgeries! When we add up these costs, hospitals spend far more on every robotic case. Unless there is clinical benefit and a particular robotic surgery is medically necessary, meaning there is some reason why another approach is not just as good or better, these costs are not justified. Unnecessary use of the robot is wasteful and burdensome.

 

What are the benefits of robotic hernia surgery?

  • Better Handling of Complicated Hernias
    • Several factors can make an inguinal hernia repair more complicated than normal, such as very large size, scar tissue from previous surgeries, or certain other medical conditions. In these cases, robotic surgery may allow better maneuvering in a scarred and complicated space – these patients can benefit from an expert robotic hernia surgeon’s use of this tool7.
  • Better Access in Patients with Large Abdomens
    • Robotic surgery may provide better visualization of the hernia site when there is a very thick layer of abdominal fat throughout the area of the hernia. 

What alternatives are there to robotic hernia surgery?

    • Open Preperitoneal Hernia Repair
      • Also known as Fast Recovery Hernia Surgery, the open preperitoneal repair involves a single, 3-4cm incision directly over the hernia site. It is done under local anesthesia with IV sedation. It allows placement of mesh in the ideal location and does not invade the abdominal cavity to get that mesh into that position. It achieves an end result identical to robotic surgery in terms of where mesh is place but allows for a far less traumatic approach to reaching that outcome. Patients recover quicker and have less pain, experience fewer complications, and have the best long term results. 
    • No-Mesh Hernia Repair
      • Similar to the open preperitoneal repair, no-mesh repairs (such as the four-layer Shouldice repair) involves a single 5-6cm incision directly over the hernia site with local anesthesia and IV sedation while avoiding the abdominal cavity. These repairs avoid mesh and instead involve stitching the hernia hole to prevent the bulging that occurs with hernias. 
    • Laparoscopic Hernia Repair
      • Laparoscopic hernia surgery does require general anesthesia and multiple incisions in the abdomen, similar to a robotic hernia repair. However, the probes are manipulated directly by the surgeon during laparoscopic surgery. Surgeons can see AND FEEL what they are doing (as compared to robotic surgery). There is no console or control panel involved. For skilled and experienced surgeons, laparoscopic hernia surgery is an excellent option for heavier patients with large abdomens.  
    • Old-Fashioned Anterior Lichtenstein Hernia Repair
      • The Lichtenstein repair involves a 5-6cm incision to access the hernia and repair the defect with mesh on the outside of or in between the muscle layers. This approach is recommended for recurrent hernias after previous open preperitoneal mesh repair, robotic mesh repair, or laparoscopic mesh repair.

 

In summary, robotic hernia surgery may be an unnecessarily risky and costly approach for most straightforward inguinal hernia repairs. Robotic hernia surgery may be appropriate when an inguinal hernia is very large and complicated or the patient has a very large abdomen. At Boston Hernia, we refer a very small minority of patients for robotic surgery for inguinal hernia. Most importantly, a surgeon’s skill level, experience, and volume of cases has a significant impact on how their patients do. It is critical that patients seek consultation from trusted, high-volume inguinal hernia specialists.

References

1. George EI, Brand TC, LaPorta A, Marescaux J, Satava RM. Origins of Robotic Surgery: From Skepticism to Standard of Care. JSLS. 2018 Oct-Dec;22(4):e2018.00039. doi: 10.4293/JSLS.2018.00039. PMID: 30524184; PMCID: PMC6261744.

2. Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Outcomes and Predictors of Complications. Huerta, Sergio et al. Journal of Surgical Research, Volume 241, 119 – 127

3. Reinhorn M, Fullington N, Agarwal D, Olson MA, Ott L, Canavan A, Pate B, Hubertus M, Urquiza A, Poulose B, Warren J. Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches. Hernia. 2023 Feb;27(1):93-104. doi: 10.1007/s10029-022-02680-0. Epub 2022 Sep 20. PMID: 36125632; PMCID: PMC9931785.

4. Prakash D, Heskin L, Doherty S, Galvin R. Local anaesthesia versus spinal anesthesia in inguinal hernia repair: A systematic review and meta-analysis. Surgeon. 2017 Feb;15(1):47-57. doi: 10.1016/j.surge.2016.01.001. Epub 2016 Feb 16. PMID: 26895656.

5. Balentine CJ, Meier J, Berger M, Hogan TP, Reisch J, Cullum M, Zeh H, Lee SC, Skinner CS, Brown CJ. Using local rather than general anesthesia for inguinal hernia repair is associated with shorter operative time and enhanced postoperative recovery. Am J Surg. 2021 May;221(5):902-907. doi: 10.1016/j.amjsurg.2020.08.024. Epub 2020 Aug 25. PMID: 32896372; PMCID: PMC7953586.

6. M M Chowdhury, H Dagash, A Pierro, A systematic review of the impact of volume of surgery and specialization on patient outcome, British Journal of Surgery, Volume 94, Issue 2, February 2007, Pages 145–161, https://doi.org/10.1002/bjs.5714

7. Lomanto Davide, Tan Lydia, Lee Sean, Wijerathne Sujith. Robotic Platform: What It Does and Does Not Offer in Hernia Surgery. Journal of Abdominal Wall Surgery. 2024:(3)2813-2092. doi: 10.3389/jaws.2024.12701