Laparoscopic versus robotic total extraperitoneal (TEP) inguinal hernia repair: a multicenter, propensity score weighted study

Purpose: The objective of this retrospective study was to assess safety and comparative clinical effectiveness of laparoscopic total extraperitoneal inguinal hernia repair (LTEP) and robot-assisted total extraperitoneal inguinal hernia repair (RaTEP) from multi-institutional experience in Taiwan. Methods: Medical records from eight hospitals in Taiwan were collected and analyzed retrospectively. Patients diagnosed of inguinal hernia, recurrent inguinal hernia and incarceration groin hernia and receiving either laparoscopic or robot-assisted TEP inguinal hernia repair between January 2018 and December 2022 were included in the study. Baseline characteristics, intra-operative and post-operative results were analyzed. To compare two cohorts, overlap Weighting was employed to balance the significant inter-group differences with a standardized mean difference less than 0.001. We also conducted subgroup analyses by state of a hernia (primary or recurrent/incarceration) and laterality (unilateral or bilateral) that indicated complexity of surgery. Results: A total of 1080 patients who underwent minimally-invasive inguinal hernia repair from 8 hospitals across Taiwan were collected. Following the application of inclusion criteria, there were 237 patients receiving RaTEP and 583 patients receiving LTEP. In the baseline analysis, RaTEP was more often performed in recurrent/incarceration (RaTEP 16.4% vs. LTEP 10.5%, p = 0.050) and bilateral cases (RaTEP 84.0% vs. LTEP 52.5%, p < 0.001). Suturing was the dominant mesh fixation method in RaTEP (RaTEP 80.2% vs. LTEP 20.4%, p < 0.001). More overweight patients were treated with RaTEP (RaTEP 59.5% vs. LTEP 50.3%, p = 0.020). After overlap weighting, there were no significant difference in intraoperative and post-operative complications between RaTEP and LTEP. Prescription rates of pain medication (opioid) were significantly lower in RaTEP than LTEP in overall group comparison (RaTEP 3.56 mg vs. LTEP 13.56 mg, p < 0.001) while operation time was significantly longer in RaTEP (RaTEP 148.83 min vs. LTEP 87.49 min, p < 0.001). Conclusions: RaTEP is safe and demonstrates surgical outcomes comparable to LTEP. It shows technical advantages in more complex hernia cases, facilitates suture fixation of the mesh, and reduces postoperative opioid use.