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Page 2 of 8 Malcher et al. Mini-invasive Surg 2021;5:31 https://dx.doi.org/10.20517/2574-1225.2021.48

advancing technology and progressing MIS, surgeons are utilizing robotic platforms to perform minimally
invasive hernia repairs following the same technical principles. This approach has been changing surgeons’
and patients’ experiences.

Robotic inguinal hernia repair has been shown as a safe alternative to laparoscopic repair by studies from
Kudsi et al. , Escobar Dominguez et al. , and Tam et al. . The robotic approach follows the same technical
[7]
[8]
[6]
principles of the laparoscopic TAPP approach. Literature review of robotic inguinal hernia repair (rIHR) is
composed of many retrospective and single-institution studies with few Randomized Controlled trials and
meta-analysis. A meta-analysis performed by Aiolfi et al. showed no differences in term of postoperative
[9]
outcomes and complications between laparoscopic and robotic approaches in the short term. A national
database review found that robotic repairs showed a lower overall complication rate when compared with
[10]
open or laparoscopic approaches .
The Robotic Inguinal vs. Transabdominal Laparoscopic Inguinal Hernia Repair (RIVAL) trial demonstrated
no added benefit for robotic surgery compared to laparoscopic surgery for unilateral primary or recurrent
hernia repairs; however, they have also concluded robotic surgery plays a role in specific settings .
[11]
Furthermore, due to technical difficulties, complex inguinal hernia repairs (scrotal hernias, incarcerated
hernias, recurrent hernias, mesh removal, and previous pelvic surgery) are a relative contraindication for
[6]
laparoscopic repairs . In this article, we highlight the advantages of the robotic approach for complex cases
of inguinal hernia.

The road map for safety in MIS hernia repair
The evolution of MIS inguinal hernia repair has mirrored the evolution of laparoscopic cholecystectomy.
Surgeons have developed an analogous idea of safety for MIS inguinal hernia repair [4,12-14] . This concept has
created a road map to maintain a safe and efficient laparoscopic approach for inguinal hernia repair. As
more and more surgeons perform MIS repair for inguinal hernias, this road map is conceptualized to
provide a standard dissection and posterior repair.

Furthermore, the posterior anatomical view of the groin might be challenging even for experienced
surgeons. Furtado et al. has developed a concept to understand the groin’s posterior anatomy by
[15]
identifying anatomical landmarks and important triangular areas to avoid injury of noble structures. The
combination of the stepwise critical view of safety with the identification of anatomical landmarks has
created a safe alternative for surgeons worldwide to perform an effective MIS inguinal hernia repair.
[4]
Claus et al. have condensed this road map in the 10 golden rules for a safe MIS inguinal hernia repair that
can be easily adapted for the robotic approach [Table 1].

Robotic inguinal hernia repair after prostatectomy
The most common complications after radical prostatectomy are impotence and urinary incontinence .
[16]
Inguinal hernia is another common complication confirmed by several studies [17-20] . A meta-analysis
published by Alder et al. has shown a high incidence of inguinal hernia after open radical prostatectomy
[16]
followed by laparoscopic and robotic prostatectomies. There was no difference between both MIS repairs .
[16]
Different studies have been published showing the feasibility of performing rIHR concomitant to radical
prostatectomies [21,22] . Clinically, non-diagnosed inguinal hernias before the surgical procedure are found in
[23]
20% to 33% of robotic prostatectomies . There is a lack of data regarding the recommended approach for
inguinal hernia repair after prostatectomies. Furthermore, the HerniaSurge guidelines recommended
surgeons to consider an anterior approach when performing hernia repair in patients with prior urologic