Letter to the Editor: A Retrospective Study Comparing the Operative Outcomes of Extraperitoneal, Retrorectus Access Laparoscopic and Robotic‐Assisted Ventral Hernia Repairs

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We appraised the findings of the study by Bindal et al. [1] at CRAMSurg (www.cramsurg.org), an online journal club based in the United Kingdom. We commend the authors for publishing a well-written paper relevant to current practice in general surgery with well-described surgical techniques. We raised the following queries and would value the authors' response. The study does not report a clear selection criterion for deciding one approach against the other and shows a tendency toward larger sized hernias being treated with the robotic approach. Furthermore, there is no mention of the site of the hernias in the abdominal wall, whether midline or off midline, and if that influenced the approach or the requirement of performing unilateral of bilateral TARs. Did the authors consider using a classification system incorporating the location and size of defects so the readers could have a better understanding of the patient population [2]? In the literature, TAR has been reported to be indicated for large ventral hernias (> 10 cm) [3] or those which are complex, with multiple defects, laterally placed in the abdominal wall or in case of previous anterior component separation [4]. All the patients in the laparoscopic group had hernias < 10 cm in the greatest dimension; however, more than 60% of the laparoscopic group was reported to have a unilateral or a bilateral TAR. In comparison, 38% of the robotic group had unilateral or bilateral TARs. The indication for doing a TAR was reported to be the tension on the posterior rectus sheath during closure, and no other objective criteria was set. The preponderance of TAR in the laparoscopic group might explain the greater operative time, worse pain scores, and QoL score in the laparoscopic group as it is a more extensive operation. Were any preoperative adjuncts like botulinum toxin injection or progressive pneumoperitoneum [5] used in any group of these patients? This may influence the ease of fascial closure. It would have been useful to report any open conversion even if there was none. One of the drawbacks of the robotic approach remains its high cost and unavailability in many centers across the world, making it difficult to generalize these results. A cost analysis of the two approaches would have been useful. Finally, from a methodological standpoint, we noticed that the univariate analysis of continuous variables was conducted using Student's t-test. Such a test becomes unreliable when applied to a nonnormally distributed dataset. Was normality tested before using it? Was consideration given to use a nonparametric test instead? We hope our feedback is useful and await in anticipation a response from the authors. Pratik Bhattacharya: conceptualization, writing – original draft, writing – review and editing. JiaXuan Tan: conceptualization, writing – original draft. Constantine Ezeme: conceptualization, writing – original draft. Giordano Perin: conceptualization, supervision, writing – original draft. The authors declare no conflicts of interest.

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