For Doctors in a Hurry
- Researchers investigated whether robotic-assisted groin hernia repair reduces long-term operative recurrence compared to laparoscopic or open surgical approaches.
- This retrospective cohort study analyzed 199,163 Medicare beneficiaries aged 65 and older who underwent groin hernia repair between 2010 and 2021.
- Robotic-assisted repair showed the highest 5-year recurrence rate at 3.78 percent, compared to 3.37 percent for open and 3.21 percent for laparoscopic.
- The researchers concluded that robotic-assisted repair is associated with a higher long-term cumulative incidence of operative recurrence than other surgical methods.
- Clinicians should evaluate alternative measures of clinical value when selecting surgical techniques, as robotic-assisted repair expands despite these higher recurrence rates.
Evolution and Economic Pressures in Groin Hernia Management
Groin hernia repair remains one of the most frequently performed operations in general surgery, with techniques evolving from traditional open repairs to various minimally invasive approaches [1, 2, 3]. The transition toward minimally invasive surgery has been driven by the potential for reduced postoperative pain, even as these methods often incur significantly higher equipment and operating room costs. For example, laparoscopic repair can cost between $1,268 and $2,000 more per procedure than open repair [4, 3]. While the Shouldice technique remains a standard for non-mesh open repair, the transabdominal preperitoneal approach (a laparoscopic method where the surgeon accesses the preperitoneal space through the abdominal cavity) has become a common alternative [1, 5]. Despite the rapid integration of robotic platforms, a previous meta-analysis of 64,568 participants found that robotic repair took 26.85 minutes longer (95% CI, 1.16 to 52.54) and was associated with a significantly higher risk of surgical site infection (odds ratio, 3.32; 95% CI, 2.63 to 4.19) compared to laparoscopy [4, 6]. A new large-scale cohort study now evaluates how these surgical choices influence the risk of operative recurrence in the aging patient population, providing critical data for surgeons weighing the clinical value of newer technologies against established methods [7].
Longitudinal Analysis of Surgical Trends in Medicare Beneficiaries
To understand how surgical trends impact patient outcomes, researchers conducted a retrospective cohort study utilizing a population-based analysis of United States inpatient and outpatient administrative claims. The analysis spanned from January 2010 to December 2021, capturing a decade of surgical evolution in the management of groin hernias. The study population consisted of 199,163 Medicare beneficiaries with a mean age of 72.6 years (standard deviation of 9.3 years). Within this large cohort, 29,307 patients (14.7%) were female. This provided a substantial sample size to evaluate long-term outcomes in an older demographic that is often characterized by multiple comorbidities and age-related tissue changes that can complicate hernia repairs.
The data revealed a significant transformation in the surgical landscape. At the start of the study period in 2010, open procedures were the predominant standard of care, accounting for 84.4% of all repairs. By 2021, the proportion of open procedures decreased 0.6-fold to 51.9%. This decline coincided with a rapid adoption of minimally invasive techniques across the country. Laparoscopic procedures, which represented 15.3% of cases in 2010, increased 3.0-fold to reach 45.5% of the total volume by the end of the study period.
The most dramatic relative growth occurred within the robotic-assisted category. Although starting from a very low baseline, the proportion of robotic-assisted groin hernia repairs increased 8.6-fold, rising from 0.3% in 2010 to 2.6% in 2021. This shift reflects a broader clinical trend toward robotic platforms in general surgery. By analyzing these trends alongside long-term recurrence data, the researchers aimed to determine if the rapid clinical adoption of robotic technology actually translates to superior anatomical outcomes for older patients.
Comparative Risk of Operative Recurrence
To evaluate the long-term durability of each surgical approach, the researchers established a primary outcome of operative recurrence up to five years after the initial repair. This extended 5-year follow-up period ensured sufficient time to capture late tissue failures that might be missed in shorter clinical trials. Data analysis for this longitudinal assessment was conducted between August 2024 and April 2025. To ensure a rigorous comparison between the three surgical modalities, the statistical analysis utilized Cox proportional hazards modeling. This statistical technique estimates the risk of an event occurring over time while adjusting for multiple confounding variables. By using this framework, the authors determined the risk-adjusted cumulative incidence of recurrence while controlling for critical clinical factors, including patient demographics, comorbidities, hernia type (inguinal or femoral), and procedure type (unilateral or bilateral).
The analysis of 199,163 beneficiaries revealed that robotic-assisted repair was associated with the highest 5-year risk-adjusted cumulative incidence of operative recurrence at 3.78% (95% CI, 3.76% to 3.79%). This rate exceeded the recurrence risk observed in both traditional and other minimally invasive techniques. Open repair resulted in a 5-year risk-adjusted cumulative incidence of operative recurrence of 3.37% (95% CI, 3.36% to 3.37%), while laparoscopic repair demonstrated the lowest 5-year risk-adjusted cumulative incidence of operative recurrence at 3.21% (95% CI, 3.21% to 3.22%). For practicing surgeons, these findings indicate that the rapid adoption of robotic platforms has not yet translated into superior long-term anatomical outcomes compared to established laparoscopic or open standards in the Medicare population.
Clinical Implications for Surgical Selection
The comparative analysis of surgical techniques reveals distinct differences in long-term durability, particularly when evaluating the laparoscopic approach against traditional standards. When compared to open repairs, the laparoscopic approach was associated with a lower risk of operative recurrence, demonstrating a hazard ratio of 0.75 (95% CI, 0.66 to 0.86). This hazard ratio (a statistical measure comparing the frequency of an event between two groups over time) indicates a 25% reduction in the relative risk of recurrence for patients undergoing laparoscopic procedures compared to those receiving open surgery. These findings suggest that for the Medicare population, the established laparoscopic method provides a statistically superior anatomical result over the five-year follow-up period.
In contrast, the data for robotic platforms did not demonstrate a similar advantage over traditional open surgery. The researchers found no statistically significant difference in the risk of operative recurrence between the open and robotic cohorts, with a hazard ratio of 1.29 (95% CI, 0.48 to 2.10). Because the confidence interval for this hazard ratio crosses 1.0, the findings do not support a definitive clinical difference in recurrence risk between these two modalities. However, when viewed across the entire study population, robotic-assisted groin hernia repair was associated with a higher long-term cumulative incidence of operative recurrence compared to both open and laparoscopic approaches.
Despite these comparative differences, clinicians should note that operative recurrence rates remained low across all surgical techniques evaluated in the Medicare cohort. With the highest risk-adjusted cumulative incidence reaching only 3.78% in the robotic group, all three modalities appear to be safe and effective options for groin hernia management. Because the absolute differences in recurrence are narrow, the authors suggest that the clinical value of robotic-assisted surgery may need to be assessed through other metrics, such as postoperative pain, recovery time, or surgeon ergonomics, rather than long-term recurrence alone. As robotic-assisted repair continues to expand in the United States, these data provide a necessary baseline for informed consent, allowing physicians to counsel older patients accurately regarding the expected durability of their hernia repair.
References
1. Delgado LM, Pompeu BF, Magalhães CM, Pasqualotto E, Barbosa WS, Figueiredo SMPD. Shouldice Versus TAPP for Inguinal Hernia Repair: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials. World Journal of Surgery. 2025. doi:10.1002/wjs.12514
2. Huerta S, Garza AM. A Systematic Review of Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Management of Inguinal Hernias in the 21st Century. Journal of Clinical Medicine. 2025. doi:10.3390/jcm14030990
3. Mills JMZ, Luscombe G, Hugh TJ. Regional variation and rising costs of groin hernia repairs in Australia: is there an urgent need for clinical consensus guidelines?. ANZ Journal of Surgery. 2022. doi:10.1111/ans.18016
4. Khewater T, Madshush AMA, Altidlawi MI, et al. Comparing Robot-Assisted and Laparoscopic Inguinal Hernia Repair: A Systematic Review and Meta-Analysis. Cureus. 2024. doi:10.7759/cureus.60959
5. Baker S, Jaiswal S, Butnari V, et al. Emergency Minimally Invasive Surgery for Obturator Hernias: A Systematic Review. Annali Italiani di Chirurgia. 2025. doi:10.62713/aic.3806
6. Zhao F, Wang B, Chen J. Comparison between robotic and laparoscopic inguinal hernia repair in Caucasian patients: a systematic review and meta-analysis. Annals of Translational Medicine. 2021. doi:10.21037/atm-21-2126
7. Rivero-Moreno Y, Goyal A, Redden-Chirinos S, et al. Clinical outcomes from robotic transabdominal preperitoneal inguinal hernia repair in patients under and over 70 years old: a single institution retrospective cohort study with a comprehensive systematic review on behalf of TROGSS - The Robotic Global Surgical Society. Aging Clinical and Experimental Research. 2024. doi:10.1007/s40520-024-02890-9
