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Invited Commentary
March 18, 2020

Robotics vs Laparoscopy—Are They Truly Rivals?

Author Affiliations
  • 1Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
JAMA Surg. 2020;155(5):388. doi:10.1001/jamasurg.2020.0052

The use of the robotic platform for primary inguinal hernia repair has been a controversial topic. In this issue of JAMA Surgery, the multicenter, pilot clinical trial by Prabhu et al1 is, to our knowledge, the first of its kind to compare outcomes of laparoscopic and robotic transabdominal preperitoneal inguinal hernia repair. The study showed no differences in postoperative outcomes between the 2 techniques, with the robotic approach incurring significantly greater operative times, total costs, and surgeon frustration. Despite the limitations of the small sample size and potential variations in the proficiency of the participating surgeons, the authors concluded that the use of the robotic platform is not recommended for primary, unilateral inguinal hernias.

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    1 Comment for this article
    Why continue to defend the indefensible
    Carlos Alvarez, MD | Sonora Regional Medical Center
    We've been told, without any objective evidence going now on 20 years, that robotic surgery is better for both surgeon and patient, and that, any day now, cost will drop. The editorialists minimize the significance of a decent randomized trial, arguing that it may have been underpowered (yet found significant differences in costs, time and surgeon frustration obvious to all unless you collect consultant fees) and suggesting participating surgeons may have been too inexperienced (while hinting, right along with Intuitive's marketing team, that the robot helps "transition" surgeons to minimally invasive approaches when in fact it largely used by newly trained specialists to gain competitive advantage). They also equate the reluctance to take up laparoscopic cholecystectomy in the 1990's to the persistent resistance to the robot. This is a straw man argument. The obvious value of laparoscopy over open surgery blew past the largely academic objections, most of which were hypothetical. All in a fraction of the time the robot has been available. Face it, robotic surgery is no longer a "new technology". We learned to do the operation safely, and bile duct injuries dropped to levels close to open surgery. We took up the robot, and nothing has changed beyond improved docking times. The VA hernia study, which I participated in, did show that inguinal hernia repair in veterans, whose average age was 75, was inferior to open repairs. It was an honest result, but for that specific population. In younger, employed patients lap repairs are better. Bias and reluctance to accept a new procedure did not guide the choice of patients for the study. The VA funded the study, and those were the patients available. It is disingenuous to imply that resistance to the robot is just old-fogey-ness redux. Laparoscopy was resisted by academic centers (most damning when we "embargoed" colon resection for cancer and took nearly a decade to figure out it was ok), while the robot is promoted by them as both a marketing tool and a generator of publications, with the not unwanted side effect of increasing faculty compensation.

    Rather than criticize this study for its size or lack of world-renowned Intuitive consultants/robotic inguinal hernia repair experts, the editorialists should commend it for what it is, a brave effort that advances surgical science.