Robotic vs. laparoscopic TAPP: a systematic review and meta-analysis of randomized controlled trials on short-term outcomes

Inguinal hernia repair is among the most frequently performed surgical procedures worldwide, with over 20 million operations each year [1, 2]. In recent decades, the technique has evolved from open repair to minimally invasive approaches, initially laparoscopic [3] and more recently robotic surgery [4], aiming to accelerate recovery, reduce both acute and chronic postoperative pain, minimize surgical site–related complications, and ultimately improve patient quality of life [5].

Robotic platforms were introduced to overcome the technical limitations of laparoscopy, offering a stable three-dimensional view, wristed instruments that replicate natural hand movements, and enhanced precision. Despite these theoretical advantages and increasing adoption, robust evidence of clinical superiority remains lacking, while higher costs compared with laparoscopy are consistently reported [6‐9].

Previous systematic reviews [6, 9‐11] have shown similar complication rates but longer operative times for robotic repair, findings that may have been confounded by the inclusion of cases performed during surgeons’ learning curves. Notably, no meta-analysis to date has focused exclusively on randomised controlled trials (RCTs), which provide the highest level of evidence for comparing surgical approaches.

This systematic review and meta-analysis synthesises RCT evidence to evaluate short-term outcomes of robotic versus laparoscopic TAPP inguinal hernia repair, with particular focus on operative time and postoperative complications.

To our knowledge, this is the first systematic review and meta-analysis exclusively restricted to randomised controlled trials, thereby providing the highest level of evidence to date regarding short-term outcomes of robotic versus laparoscopic TAPP inguinal hernia repair. Across three studies [8, 17, 18] (n = 300 patients), no statistically significant differences were identified in operative time, postoperative complications, or readmission rates.

The interpretation of operative time warrants particular caution. Although the pooled analysis suggested a longer mean duration for r-TAPP (67.3 vs. 49.4 min), differences did not reach statistical significance and must be contextualised by substantial heterogeneity between studies. Dixon et al. [17] utilised the Versius^® platform, Prabhu et al. [8] a combination of da Vinci^® Si and Xi systems, and Valorenzos et al. [18] exclusively the da Vinci^® Xi. Variations in platform type, docking time, instrument handling, and mesh fixation strategies likely contributed to the observed inconsistencies. For example, in Prabhu et al. [8], docking added only 5 min, but mesh fixation via suturing in the robotic group versus tackers in the laparoscopic group may invalidate direct time comparisons. In Dixon et al. [17], the higher BMI of patients undergoing robotic repair (27.1 ± 3.6 vs. 24.2 ± 3.5) and a lack of standardised technique further limit interpretation. Collectively, these findings indicate that operative time is a multifactorial outcome influenced by platform generation, surgical technique, and experience, rather than robotics per se. Notably, bilateral and complex hernias—known to increase operative duration—were balanced in Dixon et al. [17] and Valorenzos et al. [18] but excluded in Prabhu et al. [8] This is notable, as Arunthavanathan et al. [19], in their DIRECT trial, a post-hoc analysis of the ROLAIS dataset [18], highlighted a potential benefit of robotics precisely in such demanding cases. Other non-randomized, single-surgeon studies from high-volume centers have also reported similar results [20, 21].

Surgical expertise and the learning curve are additional critical determinants of outcomes. In Prabhu et al. [8], surgeons were required to have completed 25 prior robotic cases, but not specifically r-TAPP, while Dixon et al. [17] mandated only 20 procedures per approach, reflecting limited experience. Conversely, Valorenzos et al. [18] enrolled surgeons with ≥ 100 r-TAPPs and formal certification, effectively minimising learning-curve effects. Importantly, only this latter trial demonstrated a significant reduction in complications with robotics, underscoring the importance of structured training and substantiating the need for specialised programmes in robotic abdominal wall surgery to optimise both patient safety and resources utilization [22‐24].

This meta-analysis did not show a statistically significant reduction in complications with robotics. In particular, Valorenzos et al. [18], which included the most experienced surgeons, reported a notable reduction in 30-day complications, while Dixon et al. [17] documented faster resumption of normal activities and Prabhu et al. found no differences in quality of life. The apparently higher overall complication rate reported in the ROLAIS trial (41.5% for L-TAPP vs. 23% for R-TAPP) may largely reflect the study’s comprehensive documentation of all Clavien–Dindo grade I–II events, the inclusion of data not considered in other trials (CPIP in their study was included in the postoperative complications) and the inclusion of more complex hernias (bilateral, recurrent, or inguinoscrotal), rather than indicating a true increase in morbidity. More than 85% of all complications were minor and managed conservatively. It should also be noted that all participating surgeons routinely performed both laparoscopic and robotic TAPP repairs and had completed ≥ 100 R-TAPP procedures, which makes significant skill decay in laparoscopic procedures unlikely. These aspects suggest that the observed differences are more likely related to methodological factors than to surgical proficiency.

In terms of CPIP, although preliminary data from ROLAIS suggested a numerically lower rate of this outcome after robotic repair, current RCTs are clearly underpowered for this endpoint. Future studies systematically assessing CPIP with standardized criteria could allow future meta-analyses to determine whether robotics offers a genuine advantage in this regard.

A persistent drawback is the higher cost associated with robotic repair, primarily attributable to operating room and disposable instrument expenses, with no evidence of offsetting benefits in the short term. Nevertheless, preliminary signals from high-proficiency centres suggest that clinical advantages may become apparent as the learning curve is surpassed. Surgeons also report superior visualisation and anatomical delineation with robotic systems, potentially facilitating safer dissection, although whether these advantages yield tangible patient benefits remains to be established. Overall, robotic TAPP appears to offer short-term outcomes comparable to laparoscopy, with possible incremental benefits in experienced hands that require confirmation in higher-powered studies.

Readmission rates were uniformly low and did not differ between groups. While Valorenzos et al. [18] found a statistically significant readmission reduction with robotic repair, this was not corroborated in pooled analysis, which was likely underpowered due to small sample sizes and event rates.

Several limitations must be acknowledged (Table 2). This review is based on only three RCTs with modest sample sizes, limiting power and precision. Heterogeneity was substantial, particularly for operative time, reflecting differences in platforms, surgical techniques, and baseline characteristics (e.g., higher BMI in the robotic arm of Dixon et al. [17]). Outcome definitions were inconsistent: pain was measured with different instruments, LOS variably reported, and recurrence only captured in the short term. Dixon et al. [17] and Valorenzos et al. [18] included bilateral and complex cases, whereas Prabhu et al. [8] enrolled only unilateral hernias, limiting generalizability. Learning-curve effects likely influenced results in Prabhu et al. [8] and Dixon et al. [17], while only Valorenzos et al. [18] ensured high proficiency. All trials were open-label, raising risk of bias for subjective outcomes. Finally, costs were reported in a single trial, precluding firm conclusions on cost-effectiveness.

Despite these limitations, this review provides the most robust synthesis of RCT data currently available. Overall, the available evidence indicates that robotic TAPP achieves short-term outcomes comparable to laparoscopic repair, but definitive conclusions regarding its clinical and economic advantages remain elusive. Future research should move beyond feasibility studies toward large, collaborative, expertise-based randomized trials designed to critically assess the true utility, value, and long-term impact of robotic platforms in inguinal hernia surgery. It is unrealistic to expect universal standardization of platforms and techniques, but future studies should strive to report operative time by phase (docking, dissection, fixation, closure), describe the system used, and detail critical surgical steps. Rigorous methodological reporting will be essential to resolve ongoing debates regarding operative time. Until more definitive data are available, adoption of robotic TAPP should be tailored to available resources, surgeon experience, and patient preferences, with particular utility in complex cases and bilateral repairs once the learning curve has been overcome [20], according to operator expertise [19, 25] and for training purposes [24].

Robotic TAPP is safe and effective; however, clear superiority over laparoscopy has not yet been demonstrated, and its cost-effectiveness remains unproven and highly context-dependent. The expanding adoption of robotic platforms underscores the urgent need for rigorous, large-scale, multicentre randomized controlled trials—stratified by hernia complexity and surgeon experience, and including comprehensive economic analyses—to determine whether their use translates into tangible patient benefit. Such coordinated, collaborative efforts are essential to generate definitive evidence while maintaining balanced training pathways that preserve laparoscopic expertise in future generations of surgeons.