Robotic primary ventral hernia repair-a multi-national Delphi expert consensus

Robotic ventral hernia repair is increasing worldwide. No guidelines currently exist regarding indications for this approach, or agreed operative steps. We aimed to develop expert consensus regarding indications for robotic approaches in patients with a primary ventral hernia, and define agreed procedural steps for each robotic technique. A systematic review was undertaken and used to generate statements relating to indications, peri-operative steps and dissection techniques in robotic ventral hernia surgery. Through a nominal group technique statements were revised and piloted. A panel of international robotic hernia surgeons was established. The experts performed three rounds of a Delphi survey responding to statements in each domain. Consensus was considered achieved for any statement reaching > 80% agreement. Fifty surgeons (response rate 40%) from twenty countries completed three rounds of the Delphi process. Consensus was achieved for 107 statements. A generic treatment algorithm was developed for each robotic approach based on size classification. Each robotic approach for ventral hernias achieved consensus for their respective procedural steps – transabdominal preperitoneal, transabdominal retromuscular umbilical prosthetic hernia repair, transversus abdominis release, and enhanced view totally extraperitoneal approaches. As a multidisciplinary international group we report agreed indications, peri-operative standard operating procedures, and intra-operative technical steps for patients undergoing robotic surgery for primary ventral hernia repairs. This expert derived consensus can be utilised to standardise clinical practice, inform postgraduate surgical curriculums, and support credentialling of surgeons as proficient in robotic hernia repair.