Optimizing robotic approach to ventral hernia repair: an updated systematic review and meta-analysis between preperitoneal versus retromuscular repair

Background: The Rives-Stoppa retromuscular repair remains the reference standard for open ventral hernia repair. Advances in robotic surgery have expanded the minimally invasive options for extraperitoneal mesh placement, enabling both retromuscular and preperitoneal approaches. The robotic ventral transabdominal preperitoneal repair (Rv-TAPP), has seen increasing adoption, but comparative evidence with the robotic retromuscular techniques remains limited. Methods: A systematic review and meta-analysis were reported in accordance with PRISMA and AMSTAR II guidelines (PROSPERO 2025: CRD420251173188). Searches of PubMed, Embase, Scopus, and Cochrane Library were searched to identify comparative studies evaluating robotic preperitoneal and retromuscular ventral hernia repair. Random-effects models (DerSimonian-Laird) were used to pool weighted mean differences (WMD) and risk ratios (RR) with 95% confidence intervals (CI). Results: Six retrospective studies including 3704 patients (2326 preperitoneal, 1378 retromuscular) were included. Preperitoneal cases involved smaller, predominantly primary defects (mean 3.0 cm vs 6.3 cm). Operative time was significantly shorter for Rv-TAPP (WMD = -39.4 min, 95% CI -58.5 to -20.2; p< 0.001). Overall postoperative complications occurred in 7.2% vs 15.6%, (RR= 1.65, 95% CI 1.21-2.26), with wound-related morbidity also lower with Rv-TAPP (RR = 1.81, 95% CI 1.25-2.63). Recurrence rates were comparable (1.9% vs 0.5%; RR = 0.95, 95% CI 0.29-3.11). Conclusions: Both robotic extraperitoneal approaches are safe and effective. Rv-TAPP offers shorter operative time and lower wound morbidity without increasing recurrence rates, favouring its use in small to medium-sized or primary ventral defects. Retromuscular repair remains preferred for large or complex hernias, underscoring their complementary roles in contemporary hernia repair.