How Long Hernia Repair Recovery Robotic

JSLS. 2022 October-Dec; 24(4): e2020.00058.

Robotic Inguinal Hernia Repair Outcomes: Operative Time and Cost Assay

Morcos A. Awad, DO, Jarrod Buzalewski, Practice, Cooper Anderson, BS, James T. Pigeon, BA, Ashley Soloski, MHA, Nicole Eastward. Sharp, MD, Bogdan Protyniak, MD, and Mohsen Grand. Shabahang, Doc, PhD

Morcos A. Awad

Department of Full general Surgery, Geisinger Medical Center, Danville, PA.

Jarrod Buzalewski

Department of General Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA.

Cooper Anderson

Geisinger Commonwealth School of Medicine, Scranton, PA (Dr Anderson).

James T. Pigeon

Department of General Surgery, Geisinger Medical Center, Danville, PA.

Ashley Soloski

Department of General Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA.

Nicole Due east. Abrupt

Department of General Surgery, Geisinger Medical Center, Danville, PA.

Bogdan Protyniak

Department of General Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA.

Mohsen Thousand. Shabahang

Department of General Surgery, Geisinger Medical Middle, Danville, PA.

Abstruse

Groundwork:

Robotic inguinal hernia repair is the latest iteration of minimally invasive herniorrhaphy. Previous studies have shown expedited learning curves compared to traditional laparoscopy, which may be commencement by higher cost and longer operative time. We sought to compare operative time and direct cost across the evolving surgical exercise of 10 surgeons in our healthcare organization.

Methods:

This is a retrospective review of all transabdominal preperitoneal robotic inguinal hernia repairs performed by 10 full general surgeons from July 2022 to September 2022. Patients requiring conversion to an open procedure or undergoing simultaneous procedures were excluded. The data was divided to compare each surgeon's initial 20 cases to their subsequent cases. Direct operative price was calculated based on the sum of supplies used intra-operatively. Multivariate analysis, using a generalized estimating equation, was adapted for laterality and resident involvement to evaluate outcomes.

Results:

Robotic inguinal hernia repairs were divided into two groups: early on experience (n = 167) and tardily feel (n = 262). The belatedly experience had a shorter mean operative fourth dimension by 17.half-dozen min (confidence interval: iv.06 – 31.13, p = 0.011), a lower mean directly operative cost by $538.17 (confidence interval: 307.14 – 769.twenty, p < 0.0001), and fewer postoperative complications (p = 0.030) on multivariate assay. Thirty-day readmission rates were similar between both groups.

Conclusion:

Increasing surgeon experience with robotic inguinal hernia repair is associated with a predictable reduction in operative time, complexity rates, and direct operative cost per instance. Thirty-24-hour interval readmission rates are non affected by the learning curve.

Keywords: Inguinal hernia, Learning curve, Operative time, Cost, Robotic

INTRODUCTION

Robotic inguinal hernia repair (RIHR) is the latest innovation in minimally invasive herniorrhaphy. There is a growing number of inguinal hernia repair (IHR) performed via the robotic approach, and predictors of RIHR seem to include larger not-didactics rural hospitals, and surgeons with lower almanac case volume.^1,two Touted benefits to RIHR include improved visualization and dexterity, evidenced by the decreased minimally-invasive suturing task time learning curve in the robotic compared to laparoscopic approach in a fake sitting.³ One benefit of the robotic arroyo is the power to repair incidental contralateral hernias, given that as high as 15.viii% of patients are reported to accept contralateral inguinal hernias identified intra-operatively during RIHR.^four Other advantages to the robotic technique include its effects on the postoperative experience. Studies take reported improved postoperative pain, shorter use fourth dimension of prescribed pain medication, lower mail service-anesthesia-care-unit of measurement (PACU) recovery fourth dimension, and a trend toward sooner render to work compared to laparoscopic inguinal hernia repair (LIHR).^5,6 Such advantages to RIHR are offset by the prolonged intra-operative time and higher toll compared to the laparoscopic approach.^7,eight

Most studies compare RIHR to the laparoscopic and open approaches. A few studies, however, endeavour to analyze a surgeon'due south learning curve in RIHR beyond time. A recent multi-center study including 335 RIHR cases performed past eighteen surgeons showed a learning bend of 11 – 12 cases for one of the involved surgeons, based on consecutive 24 cases performed.^nine Multiple other studies describe the minimum number of cases necessary to reach a learning curve in robotic intestinal surgery in general. In robotic abdomino-perineal resection and anterior resection for rectal cancer, one study of 43 cases used cumulative sum analysis to show a minimum of 21 – 23 cases needed to attain the learning bend.¹⁰ Another study including 62 cases of segmental colectomies, proctectomies, and rectopexies compared the first consecutive 15 cases to the remainder of cases.^xi The report showed a reduced operative time and complexity rates in the latter group, which may reflect a learning curve of fifteen cases. Some other report including 19 cases of robotic radical hysterectomy with lymph node dissection for cervical cancer used cumulative sum analysis to evidence a minimum of thirteen cases required to reach the learning curve.¹² Based on the in a higher place studies, it seems that the learning curve of robotic abdomino-pelvic surgery ranges by and large between 15 to 23 cases.^ix–12

Most previous studies compare RIHR to laparoscopic and open IHR, showing increased operative time and cost in the robotic technique.^vii,thirteen However, the previous studies of robotic abdomino-pelvic surgery accept smaller sample size and do not seem to examine such outcomes across the learning curve. The aim of this study is to compare intra-operative time, straight operative toll, and postoperative complication rate between an early on and a late phase of RIHR learning curve of multiple surgeons.

METHODS

This is a retrospective analysis of consecutive, elective robotic transabdominal preperitoneal (R-TAPP) cases performed by x surgeons at two institutions in our healthcare organization from July 2022 to September 2022. Adults 18 years sometime or older who underwent unilateral or bilateral RIHR were included in the study. Cases were excluded from the study if they were converted to open hernia repair. With the exception of patients undergoing primary umbilical hernia repair at the site of umbilical trocar insertion, patients undergoing significant concurrent procedure were excluded equally well.

The written report population was divided into two groups: early on experience (divers as the first 20 cases of each surgeon's RIHR feel) and late experience (defined equally the residue of each surgeon's RIHR experience). The 20-case cutoff was assigned based on the above-mentioned literature review showing a robotic-surgery learning curve ranging between fifteen and 23 cases. Of note, iii of the ten surgeons had performed fewer than xx cases; with a range of viii to eleven cases, thus had only their early feel included. Demographics included age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and previous ipsilateral IHR. Master outcomes included intra-operative time and straight operative toll. Secondary outcomes included the rate of postal service-operative complications, xxx-24-hour interval readmission rate, surgical resident involvement, and change in admission condition. Modify in admission status was identified as a change from the expected outpatient status of the surgery to an inpatient or overnight 23-60 minutes admission secondary to whatever cause. Of notation, modify in access condition did not include patients who were planned to undergo access secondary to their comorbid conditions.

Given that bilateral RIHR is presumed to accept longer operative time compared to unilateral RIHR and that resident involvement may contribute to a longer operative fourth dimension, a multivariate analysis was performed adjusting for both factors. Variables analyzed in the multivariate model included operative time, directly operative cost adjusted for fiscal yr, postoperative complications, and 30-twenty-four hour period readmission rate. Operative cost was directly cost; including mesh cost, instrumentation price (i.e. robotic arm instruments, insufflation tubing), and other supplies (i.due east. sutures, gauzes, trocars). Operative cost excluded intra-operative fourth dimension cost because it is reflected by the intra-operative fourth dimension comparing analysis. It likewise excluded the indirect cost of robotic personnel and robot maintenance, given that this mensurate would be the aforementioned throughout the early and late feel of RIHR.

Patient characteristics were summarized using continuous and chiselled variables. Continuous variables are presented as mean ± standard difference (SD). Chiselled variables are presented as frequency with a percentage, n (%). The t-test and Chi-squared test were used for comparison. In a multivariate assay, logistic and linear regression models with generalized estimating equations were used to command for potential misreckoning. Results are presented equally hateful difference or odds ratio (OR) with a 95% confidence interval (CI). Data were analyzed using the SAS® Version 9.4 statistics software (SAS Institute, Cary, NC). A p value < 0.05 was considered statistically significant. The study was canonical past the Institutional Review Board.

RESULTS

Figure ane depicts the study population. Excluded cases were either due to patients undergoing a meaning concurrent procedure other than primary umbilical hernia repair at the trocar site insertion (northward = 17), or due to conversion to open hernia repair (n = 17). Cases were converted to open hernia repair if the patient could non tolerate pneumoperitoneum secondary to comorbid conditions, if the hernia sac could not be safely dissected secondary to all-encompassing adhesive illness or prior mesh presence, and if the hernia could not be safely reduced secondary to bladder or intestinal involvement. Concurrent procedures that necessitated exclusion from the report included umbilical hernia repair with mesh, hysterectomy, prostatectomy, excision of a previous inguinal mesh, intra- or extra-intestinal cyst or mass removal, cystoscopy with dilation, and hiatal hernia repair.

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A full of 429 patients were included in the study assay. Of those, 167 patients were included in the early experience and 262 patients in the late experience. Both groups had like average historic period and BMI, gender distribution, and ASA classification ( Table 1 ). In full, 74 patients (17.2%) had at to the lowest degree one previous ipsilateral IHR, which was similar between both groups; p = 0.398. There were 315 (73.4%) unilateral and 114 (26.half-dozen%) bilateral RIHR cases, which was similar betwixt both groups as well; p = 0.088.

Table one.

Comparison of Early on and Belatedly Experience in Robotic Inguinal Hernia Repair

Variables	Early Experience (northward = 167)	Tardily Feel (n = 262)	p Value
Demographics
Age (year)	56.8 ± fifteen.0	55.iv ± xiv.6	0.340
Male	161 (96.4%)	250 (95.4%)	0.619
BMI (kg/chiliad^two)	27.4 ± iv.5	27.7 ± v.6	0.572
Prior ipsilateral hernia repair	31 (18.6%)	43 (xvi.iv%)	0.398
ASA Classification			0.606
I	14 (viii.9%)	24 (9.8%)
Ii	94 (59.v%)	154 (62.six%)
III	l (31.7%)	66 (26.8%)
Iv	0 (0%)	two (0.viii%)
Operative Variables
Laterality			0.088
Unilateral	115 (68.9%)	200 (76.3%)
Bilateral	52 (31.i%)	62 (23.vii%)
Resident Involvement	86 (51.v%)	165 (63%)	0.019
Change in Admission Condition	14 (eight.4%)	5 (1.9%)	0.002
Univariate Analysis
Operative Time (min)	110.9 ± 41	86.nine ± 28	< 0.0001
Post-operative Complications	25 (fifteen%)	23 (8.8%)	0.047
xxx-Day Readmission	v (3%)	4 (1.5%)	0.320

In univariate analysis, intra-operative time was shorter in the belatedly experience compared to the early on experience; 86.9 ± 28 vs. 110.ix ± 41 minutes, p < 0.0001 ( Table 1 ). In multivariate analysis, adjusting for resident involvement and laterality, the late experience was associated with a shorter intra-operative fourth dimension by 17.6 (95% CI: 4.06 – 31.thirteen) minutes per case on average, p = 0.011 ( Table 2 ). Prior to the adjustment, bilaterality resulted in a longer intra-operative time past 31.48 (95% CI: 27.04 – 35.92) minutes; p < 0.0001, and there was a tendency toward a longer intra-operative fourth dimension by 7.lx (95% CI: 0.60 – 15.lxxx) minutes, in cases with resident interest, but the departure was insignificant; p = 0.069. Of note, resident involvement occurred more frequently in the late experience; 63% vs. 51.five%, p = 0.019 ( Table 1 ).

Table 2.

Multivariate Analysis: Association with Tardily Experience in Robotic Inguinal Hernia Repair

Operative Variables	Mean Deviation	95% CI	p Value
Intra-operative time reduction (min)	17.60	4.06 – 31.13	0.011
Operative cost reduction ($, adjusted for fiscal year)	538.17	307.xiv – 769.20	< 0.0001


Postoperative Variables	Odds Ratio	95% CI	p Value
Postoperative complications	0.639	0.427 – 0.957	0.030
30-Mean solar day readmission	0.615	0.259 – 1.458	0.270

In univariate analysis, there was a tendency toward less straight operative cost in the tardily feel compared to the early experience; $1998 ± $637 vs. $2128 ± $730, p = 0.053. In multivariate analysis adjusting for resident involvement, laterality, and fiscal twelvemonth, the late experience was associated with a reduced operative cost by $538.17 (95% CI: $307.14 – $769.twenty) per example on boilerplate, p < 0.0001 ( Table 2 ). Prior to the adjustment, bilaterality resulted in a higher operative cost by $438.38 (95% CI: $338.02 – $538.74), p < 0.0001; still, resident interest was not associated with a higher operative cost; $38.73 (95% CI: $40.84 – $118.29), p = 0.34. Prior to adjustment for fiscal year, there was an associated increase in operative cost per year; in 2022 by $727.07 (95% CI: $557.98 – $896.15), and in 2022 by $875.41 (95% CI: $662.42 – $1088.39), all p < 0.0001.

In univariate analysis, at that place was no difference in 30-day readmission rates between the early and belatedly experience; 3% vs. one.five%, p = 0.320 ( Tabular array 1 ). In multivariate analysis adjusting for resident interest and laterality, there was no association betwixt the belatedly feel and 30-day readmission charge per unit, OR = 0.615 (95% CI: 0.259 – i.458); p = 0.270 ( Tabular array two ). At that place were ix patients (ii.i%) readmitted within thirty days postoperatively. Reasons for 30-day readmission included the following: independent perforated gastric ulcer, suicidal ideation, urinary memory, dysphagia, dyspnea, chronic obstructive pulmonary illness exacerbation, astute kidney injury, and infectious colitis. The one patient with urinary retention was readmitted on postoperative day 3 and the one patient with kidney injury was readmitted on postoperative mean solar day 2; each stayed in the infirmary for less than two days.

In univariate assay, the rate of post-operative complications was lower in the late experience; 8.8% vs. fifteen%, p = 0.047 ( Table 1 ). In multivariate analysis, adjusting for resident involvement and laterality, the late feel was associated with a lower rate of mail service-operative complications too; OR = 0.639 (95% CI: 0.427 – 0.957), p = 0.030 ( Table 2 ). Postal service-operative complications occurred in 48 patients (11.two%) during an average follow-up time of 44.8 ± 75.ix days. 20-three patients (5.4%) experienced urinary retentiveness requiring catheterization. One of those patients acquired a urinary tract infection requiring treatment, one patient experienced astute kidney injury requiring access and fluid resuscitation, and 1 patient experienced atrial fibrillation postoperatively requiring admission. Of those 23 patients, 6 patients were on an blastoff-ane receptor blocker, 1 patient had a history of prostate cancer, one patient was later on diagnosed with urothelial carcinoma, and nine patients had documented enlarged prostate; 7 of whom were on at least an alpha-one receptor blocker and/or a 5-alpha reductase inhibitor. Six patients had none of the in a higher place history.

Eleven patients (ii.6%) experienced chronic pain, defined equally ≥ 12 weeks postoperatively; 4 of whom required medical therapy past interventional pain specialists. No patient required re-operation for chronic pain. Other complications included two patients (0.v%) with postoperative seroma formation requiring aspiration, one patient (0.2%) with wound infection requiring antibiotics, 1 patient (0.two%) with wound granuloma germination requiring in-office handheld cauterization, 3 patients (0.seven%) with urinary tract infection requiring antibiotic treatment, i patient (0.2%) with stridor requiring re-intubation with admission, one patient (0.2%) with non-ST-elevation myocardial infarction requiring admission, and ane patient (0.2%) with a Clostridium difficile infection requiring treatment. Given some of the above complications or planned postoperative admission, a few patients were admitted later RIHR. Notwithstanding, change in admission condition occurred less oft in the tardily feel; ane.9% vs. eight.iv%, p = 0.002 ( Table ane ).

Of annotation, one patient in the early experience acquired a small incisional hernia at the umbilical trocar site and one patient in the tardily feel acquired an epigastric hernia along with an incisional hernia at the umbilical trocar site requiring mesh repair after 225 days postoperatively. Two patients (0.5%) had tardily recurrent inguinal hernia requiring intervention. The get-go patient, who had a history of left IHR, underwent a left RIHR in this study (tardily experience), and developed recurrent left inguinal hernia requiring open up repair with mesh later 320 days of electric current surgery. The 2d patient, who had no history of IHR, underwent bilateral RIHR in this study (early experience), and adult recurrent right inguinal hernia requiring open repair with mesh after 301 days of electric current surgery.

Discussion

Multiple studies accept analyzed operative time and cost, as well equally postoperative recovery time and pain, between the robotic and laparoscopic arroyo to IHR. A single-surgeon feel of 24 LIHRs and 39 RIHRs showed significantly reduced recovery-room time (109.1 vs. 133.5 min) and pain score (2.5 vs. 3.viii) in the robotic group compared to the laparoscopic grouping.⁵ In a propensity-matched assay, patients without a prior IHR reported a significantly reduced postoperative inguinal hurting score at one calendar week in RIHR compared to LIHR and open IHR (3.8 vs. 4.9 vs. v.five, respectively).⁶ In the same study, a subgroup of patients who underwent RIHR reported significantly shorter fourth dimension to stopping the utilise of prescribed pain medication postoperatively compared to LIHR and open IHR (ix vs. 12.6 vs. 11.2 days, respectively). A non-statistically-significant trend was likewise reported toward a faster render-to-piece of work in the RIHR group compared to the LIHR and open IHR groups (18.two vs. 21.ane vs. 23.6 days, respectively), in a subgroup of patients.⁶ Every bit discussed before, previous studies have shown prolonged operative time and higher cost, while likewise having an improved recovery time and postoperative pain in robotic compared to laparoscopic IHR.^{5–8,thirteen,14} No written report, with a significant population size, analyzed whether such outcomes change with a surgeon's growing RIHR experience beyond the learning curve. To our knowledge, this is the largest RIHR experience in literature to accost this topic.

We show that increasing surgeons' experience with RIHR correlates with a shorter intra-operative time; especially later 20 cases, reaching a 17.vi-min reduction in the late compared to the early feel. A previous multi-institutional written report showed a longer intra-operative (125 vs. 90 min), operative (87 vs. 56 min), and PACU (70 vs. 59 min) time in the RIHR group.⁷ However, length of stay seemed to exist similar between RIHR and LIHR in primary and recurrent repairs; ranging from 0.24 to 0.26 days. Another study, in a defended minimally-invasive surgery center, showed an increased mean operative fourth dimension in RIHR compared to LIHR (116 vs. 95 min, p < 0.01); with a significantly longer operative time in unilateral IHR (110 vs. 88 min, p < 0.01) and a trend toward longer operative time in bilateral IHR (143 vs. 114 min, p = 0.06) in the robotic grouping.⁸ All the same, a study of one surgeon's experience showed a reduction in the operative time of R-TAPP IHR during the learning curve, to reach a similar operative fourth dimension of laparoscopic TAPP.^fifteen A similar written report showed a reduction in operative fourth dimension of robotic inguinal and ventral hernia repairs every bit surgeons' experience increased; reaching a similar fourth dimension as the laparoscopic repairs.^xvi A recent study analyzed the start 24 unilateral RIHR cases of one surgeon and recognized a change in operative time after the first 11 cases; marking the learning curve at this signal;^nine however, information technology was a unmarried surgeon's experience of only the first 24 cases. A larger sample size would be required to recognize a defined learning-bend case-number. Based on our results, intra-operative time of RIHR is shorter as experience increases over time.

In this written report, nosotros show that with an increasing surgeons' feel with RIHR, in that location is a reduction in average direct operative toll per instance; particularly after 20 cases, reaching a $538.17 reduction in the late compared to the early experience. Based on a previous large study, RIHR has a much higher average total hospital cost ($5517 vs. $3269) and stock-still cost (medical device; $1272 vs. $172, and personnel; $3312 vs. $1992), simply less variable toll (reusables and disposables; $933 vs. $1105), compared to LIHR.⁷ Another study comparing 69 RIHRs to 241 LIHRs showed dr. charges to be the aforementioned betwixt both groups ($2663 vs. $2239), but RIHR had a higher hospital cost ($7162 vs. $4527) and total hospital charge ($27,017 vs. $16,016) compared to LIHR.¹³ Similarly, a report in a dedicated minimally-invasive surgery centre, comparing 45 RIHRs to 138 LIHRs, showed an increased full hospital cost ($9994 vs. $5995), mesh cost ($468 vs. $330), and other supplies price ($679 vs. $454); but a lower admission instruments cost ($190 vs. $269) in RIHR compared to LIHR, with a similar total cost of dispensable supplies ($1588 vs. $1380).⁸ All the above studies compare summative robotic and laparoscopic IHR cost; nevertheless, none compare either the early or tardily robotic feel to the laparoscopic approach. One small study of a single surgeon'south experience with 39 R-TAPP and 24 laparoscopic TAPP cases showed equivalent average direct costs of $3479 in RIHR compared to $3216 in LIHR.⁵ Our operative toll analysis included straight cost: mesh toll, variable cost (reusables and disposables), and access instruments toll. Based on our results, direct operative cost of RIHR is reduced as experience increases over time. This is likely due to the consistency and stability of instrumentation use that surgeons develop across their learning bend with experience over time.

This current study also found that postoperative complications decreased with increasing RIHR experience; from 25/167 patients (fifteen%) in the early experience to 23/262 patients (viii.eight%) in the belatedly experience. The most prevalent complexity was urinary retention requiring catheterization in 23 patients (v.four%). Prior studies accept reported urinary retention rates after RIHR within the range of iii.three% to x.2% with some reportable similarity to LIHR.^{8,9,fifteen,17,18} The 2d most prevalent complication was chronic pain in 11 patients (2.vi%). Prior studies have reported 2.4 to 14.ane% rates of inguinodynia afterward RIHR with some reportable similarity to LIHR.^9,17 However, a recent study showed higher postoperative complications in RIHR compared to LIHR; with Clavien-Dindo Course I-II in 10/45 patients (22.2%) and Clavien-Dindo Form III-Four in 3/45 patients (6.seven%) in the robotic arroyo compared to Clavien-Dindo Grade I-Two in 25/138 patients (xviii.1%) and Clavien-Dindo Class III-IV in 0/138 patients in the laparoscopic approach.^viii In that study, information technology is of import to note that patients in the RIHR group had a higher rate of chronic kidney disease and obstructive slumber apnea pre-operatively. In improver, 1 of iv surgeons performed all robotic cases while all four surgeons performed the laparoscopic cases. The same report also reported a higher 30-day readmission rate in the RIHR compared to LIHR group; 3/45 patients (6.7%) vs. 1/138 patients (0.7%), respectively.⁸ In our current written report, only 9 of 429 patients (2.one%) who underwent RIHR required readmission within 30 days mail service-operatively; with no difference between the early on and late experience of RIHR. Another study, comparison 1100 open up IHRs to 128 LIHRs and 71 RIHRs, reported higher postoperative complications in the minimally invasive approaches compared to the open approach, with recurrence in iv/71 patients (5.6%) who underwent RIHR.¹⁷ In this current written report, we report a recurrence in 2 of 429 patients (0.5%) who underwent RIHR. In full, our study shows reduced postoperative complications with increasing RIHR experience, with depression recurrence rates, and similar and depression 30-day readmission rates in the early and late RIHR experience. This further reflects improved surgeons comfort level and outcomes with the robotic approach over fourth dimension.

Overall, this current study supports the notion that intra-operative time, direct operative toll, and postoperative complication rates decrease with increasing surgeon'southward RIHR experience across the learning bend. Such findings question whether information technology is necessary to comprise RIHR as part of the curriculum of general surgery residency. A big study showed an increase in the number of robotic inguinal and ventral hernia repairs, with a correlated increase in resident involvement and noted differences in participation of post-graduate year (PGY) level.¹⁹ Previous studies showed no departure between operative time and postoperative complication rates between RIHR cases with and without resident involvement.^9,20 Even so, a recent R-TAPP study of 27 residents at PGY levels two – 4 and two attending surgeons reported a longer average operative fourth dimension for residents (53.0 min vs. xxx.8 min; p = 0.01) compared to attending surgeons.¹⁸ The same report showed that residents who self-reportedly completed ≤ 10 cases had lower mean robotic-skill assessment scores, while those who completed ≥ 30 cases had higher mean scores. This shows improved autonomy to residents equally their extent of involvement increases overtime, which tin can be reflective of the increased attention surgeon's comfort level with RIHR as they reach their ain learning curve. Our current report shows an increased resident involvement in the late compared to early RIHR feel; despite having lower intra-operative time, straight operative price, and postoperative complications in the late feel. We believe this reflects advances in surgeons' efficiency as their RIHR experience develops.

Although this is the largest calibration RIHR feel in a single healthcare arrangement to appointment, at that place are limitations to the written report including its retrospective nature. There is likewise operative heterogeneity given the involvement of 10 surgeons in two centers utilizing both Xi and Si DaVinci robot. Furthermore, surgeons were variable based on their years in practise and previous laparoscopic hernia repair experience. Of notation, the extent of resident interest (bedside or panel participation) could non exist accurately and consistently measured for the purpose of this study. However, the teaching opportunity is more than evident in the late experience based on the increased number of involved residents in the cases.

CONCLUSION

Surgeons show higher efficiency and improved postoperative outcomes after gaining experience in RIHR. Afterward a 20-case learning experience, surgeons tin decrease their boilerplate operative time past 17.six min and their average direct case cost by $538.17. Although previous studies show increased operative price and time in the robotic compared to the laparoscopic approach to IHR, based on the above findings, this likely changes over time as surgeons gain more experience with the robotic arroyo and reach their learning bend. Future studies should focus on assessment of the RIHR learning curve with operative time, cost, and outcomes. Larger scale studies are needed to analyze such outcomes, comparison early on and tardily experience of RIHR to LIHR. Information technology is besides not known whether surgeons' previous laparoscopic training affects their RIHR learning curve.

Contributor Information

Morcos A. Awad, Department of General Surgery, Geisinger Medical Heart, Danville, PA.

Jarrod Buzalewski, Department of General Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA.

Cooper Anderson, Geisinger Commonwealth School of Medicine, Scranton, PA (Dr Anderson).

James T. Dove, Section of General Surgery, Geisinger Medical Centre, Danville, PA.

Ashley Soloski, Department of Full general Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA.

Nicole Due east. Sharp, Section of Full general Surgery, Geisinger Medical Center, Danville, PA.

Bogdan Protyniak, Section of General Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA.

Mohsen M. Shabahang, Department of General Surgery, Geisinger Medical Middle, Danville, PA.

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