Title and article structure
This article is organized to reflect the clinical and policy relevance of the study: clinical background, study design and methods, major findings, interpretation for surgical practice, limitations and external validity, and implications for value-based adoption of robotic surgery.
Highlights
First, in a national cohort of 199 163 Medicare beneficiaries aged 65 years and older, long-term operative recurrence after groin hernia repair was uncommon across all approaches, with absolute 5-year risks near 3% to 4%.
Second, laparoscopic repair was associated with the lowest risk-adjusted cumulative incidence of operative recurrence at 5 years (3.21%), compared with open repair (3.37%) and robotic-assisted repair (3.78%).
Third, compared with open repair, laparoscopic repair was associated with a lower hazard of operative recurrence (HR, 0.75; 95% CI, 0.66-0.86), whereas robotic-assisted repair did not demonstrate a clear recurrence advantage over open repair.
Fourth, robotic-assisted groin hernia repair increased 8.6-fold during the study period, despite limited evidence of superior long-term effectiveness on this outcome, underscoring the need to evaluate broader measures of surgical value.
Background
Groin hernia repair is among the most commonly performed general surgical procedures in the US, and inguinal hernias account for the large majority of cases. For decades, surgeons have selected between open and minimally invasive approaches based on patient factors, hernia anatomy, recurrence history, anesthesia considerations, postoperative recovery goals, and local expertise. In the last several years, robotic-assisted repair has entered this space rapidly, particularly in hospitals with growing robotic platforms and surgeon training pathways.
Yet the central question is whether the robotic approach improves outcomes that matter. For groin hernia repair, recurrence is one of the most consequential long-term endpoints, although it is only one dimension of effectiveness. Pain, neuralgia, time to return to activity, operative duration, complications, and cost also shape the value proposition. Existing randomized and observational studies have often been underpowered for long-term recurrence, especially for robotic repair, or limited to single centers and short follow-up. That gap makes population-level data particularly useful, even when derived from administrative claims.
The present study by Niba and colleagues, published in JAMA Surgery in 2026, addresses this evidence gap by comparing long-term operative recurrence after robotic-assisted, laparoscopic, and open groin hernia repairs in older US adults insured through Medicare. Because robotic adoption has outpaced definitive comparative effectiveness evidence in many procedural fields, the findings are relevant not only to hernia surgeons, but also to hospital leaders, payers, and policymakers.
Study design and methods
Design and data source
This was a retrospective cohort study using US Medicare inpatient and outpatient administrative claims. The investigators identified groin hernia repairs performed from January 2010 through December 2021 and assessed outcomes with up to 5 years of follow-up. Data analysis was conducted between August 2024 and April 2025.
Population
The cohort included 199 163 Medicare beneficiaries aged 65 years and older undergoing groin hernia repair. The mean age was 72.6 years, and 14.7% of patients were women. The use of a Medicare population is important for scale and follow-up completeness, but it also means the study chiefly reflects outcomes in older adults rather than younger working-age populations, who comprise a substantial proportion of inguinal hernia patients in routine practice.
Exposure groups
Patients were categorized according to surgical approach: robotic-assisted, laparoscopic, or open groin hernia repair. The study also adjusted for hernia type, distinguishing inguinal from femoral hernias, and for procedure laterality, including unilateral and bilateral repairs.
Outcome
The primary endpoint was operative recurrence within 5 years after the index hernia repair. This outcome captures reoperation for recurrence rather than all clinically detected recurrences. That distinction matters. Operative recurrence is highly specific and clinically meaningful, but it may underestimate true anatomic or symptomatic recurrence because some patients with recurrent hernias are managed conservatively or never return for surgery.
Statistical approach
The authors used Cox proportional hazards modeling to estimate risk-adjusted cumulative incidence of operative recurrence up to 5 years. Models controlled for patient demographics, comorbidities, hernia type, and whether the repair was unilateral or bilateral. This analytic strategy is appropriate for time-to-event comparison, although residual confounding is inevitable in observational studies, especially where surgeon selection and institutional factors are not fully captured.
Key findings
Procedure adoption changed substantially over time
The most striking secular trend was the rapid uptake of minimally invasive approaches, particularly robotic surgery. From 2010 to 2021, the proportion of robotic-assisted groin hernia repairs increased 8.6-fold, from 0.3% to 2.6%. Over the same interval, laparoscopic repair increased 3.0-fold, from 15.3% to 45.5%, while open repair declined from 84.4% to 51.9%.
This pattern shows that open repair still accounted for the majority of groin hernia repairs in this older population by the end of the study period, but minimally invasive surgery had become far more common. The robotic share remained smaller than the laparoscopic share overall, yet its growth trajectory was steep, reflecting broader diffusion of robotic technology across US surgical practice.
Absolute recurrence rates were low across all approaches
At 5 years, the risk-adjusted cumulative incidence of operative recurrence was low regardless of operative technique. Robotic-assisted repair had the highest estimated 5-year cumulative incidence at 3.78% (95% CI, 3.76%-3.79%). Open repair followed at 3.37% (95% CI, 3.36%-3.37%), and laparoscopic repair had the lowest rate at 3.21% (95% CI, 3.21%-3.22%).
The differences in absolute risk were modest, measured in fractions of a percentage point rather than large clinically dramatic separations. This point is important for interpretation. Even if one technique is statistically favored over another, the overall long-term need for reoperation was uncommon. Therefore, recurrence alone may be too narrow an endpoint to justify substantial differences in technology cost or platform investment.
Comparative hazards favored laparoscopy over open repair
When compared with open repair, laparoscopic repair was associated with a lower hazard of operative recurrence, with an HR of 0.75 (95% CI, 0.66-0.86). This finding supports the durability of laparoscopic groin hernia repair in appropriately selected older adults and is broadly aligned with prior evidence supporting minimally invasive posterior repair, particularly in bilateral or recurrent disease when performed by experienced surgeons.
For robotic-assisted repair, the abstract reports no difference in risk of operative recurrence relative to open repair, while also listing an HR of 1.29 with a 95% CI of 0.48-2.10. As presented, the confidence interval includes 1, indicating statistical nonsignificance. The point estimate numerically trends toward higher recurrence with robotics, but the interval is wide enough that the study does not establish a definitive difference from open repair on a hazard basis. Nonetheless, the cumulative incidence estimates suggest that robotic repair was not superior to either comparator for the primary long-term endpoint.
How should clinicians read the apparent discrepancy?
There is a subtle but important distinction between the cumulative incidence estimates and the hazard ratio comparison. The risk-adjusted 5-year cumulative incidence was highest in the robotic group, yet the hazard ratio versus open repair was not statistically significant. This may reflect smaller sample size in the robotic cohort, fewer events, or greater uncertainty after multivariable adjustment. In practical terms, the study does not support a recurrence advantage for robotic groin hernia repair and raises concern that its long-term durability is at best comparable, and possibly somewhat less favorable, than established approaches.
Clinical interpretation
What do these findings mean for surgeons?
For general surgeons and hernia specialists, the most clinically actionable result is that laparoscopic repair was associated with the lowest long-term operative recurrence among the three approaches in this Medicare cohort. That does not mean laparoscopy is universally best for every patient. Open repair remains highly effective, especially in patients with contraindications to general anesthesia, those with large scrotal hernias, or in settings where surgeon expertise strongly favors open anterior repair. But in environments where both open and laparoscopic options are readily available and technically feasible, these data reinforce the long-term durability of laparoscopic repair.
For robotic-assisted repair, the study suggests caution against assuming technological novelty translates into improved long-term recurrence outcomes. Robotic systems may offer ergonomic advantages for surgeons and technical convenience for intracorporeal suturing or complex abdominal wall dissection. However, for routine groin hernia repair, those theoretical benefits did not translate into a measurable recurrence advantage in this older national cohort.
Why might laparoscopy perform well?
Several mechanisms are plausible. Laparoscopic groin hernia repair uses a posterior preperitoneal approach that enables wide myopectineal coverage with mesh, particularly advantageous in bilateral hernias and in detecting occult contralateral defects. When performed proficiently, it may reduce technical blind spots associated with some open repairs. It is also possible that surgeons selecting laparoscopy had greater specialization or treated patients with characteristics favoring this approach, although the authors adjusted for several measured confounders.
What about patient-centered outcomes beyond recurrence?
This study appropriately focuses on operative recurrence, but it cannot answer several questions that matter to patients and health systems. Robotic and laparoscopic repairs may differ from open repair in postoperative pain, opioid use, recovery time, return to usual activity, wound complications, urinary retention, and chronic groin pain. Likewise, costs, operative times, disposable equipment use, and capital investment are critical when judging value. The authors’ conclusion that alternative measures of clinical value may be necessary is therefore well taken. In a low-recurrence operation, small durability differences may be less decisive than recovery, quality of life, and cost-effectiveness.
Strengths of the study
The study has several notable strengths. It is large, population-based, and national in scope. Follow-up extends to 5 years, which is far more informative for hernia recurrence than the short-term horizons used in many procedural studies. The inclusion of both inpatient and outpatient claims improves capture of contemporary surgical practice, and the use of risk adjustment enhances comparability across groups. Perhaps most importantly, the study addresses a live policy question: whether rapid diffusion of robotic surgery in common operations is supported by long-term effectiveness data.
Limitations and sources of bias
As with all retrospective claims-based studies, interpretation requires caution. Administrative data lack granular anatomic and operative details such as hernia size, direct versus indirect morphology, recurrent versus primary status if incompletely coded, mesh type, fixation method, conversion to open surgery, operative duration, and surgeon-specific experience. These factors can strongly influence recurrence risk.
Selection bias is another major issue. Surgeons may preferentially choose robotic repair for patients perceived as more complex, for bilateral disease, for obesity, or based on local workflow and technology access. Although multivariable adjustment addresses measured covariates, unmeasured confounding remains likely. In addition, operative recurrence is not synonymous with total recurrence burden. Some older adults with recurrent groin symptoms may not undergo reoperation because of frailty, limited symptoms, or preference, causing underascertainment of the true recurrence rate.
Generalizability is also restricted. The study population was limited to Medicare beneficiaries aged 65 years and older. Outcomes may differ in younger adults, women of reproductive age, patients with physically demanding occupations, and health systems outside the US. Finally, the robotic cohort, especially in earlier years, was relatively small, which may explain the wide confidence interval around the robotic versus open hazard ratio.
Context with existing evidence and guidelines
Current international groin hernia guidance has generally supported mesh-based repair tailored to patient and surgeon factors, with minimally invasive posterior approaches often favored for bilateral hernias and recurrent hernias after prior anterior repair when expertise is available. The HerniaSurge international guidelines and subsequent updates emphasize that outcomes in hernia surgery are highly dependent on surgeon experience, volume, and adherence to technique-specific best practices.
The present study fits that framework. It does not overturn the role of open repair, nor does it prove robotic surgery is inferior in every circumstance. Rather, it suggests that for the specific endpoint of long-term operative recurrence in older adults, robotic-assisted repair has not yet demonstrated superiority over the more established laparoscopic approach and may not justify adoption on durability grounds alone.
These findings also align with a broader pattern seen in procedural innovation: expensive platforms often diffuse before long-term comparative effectiveness is settled. In such settings, it becomes essential to ask not only whether a technology works, but whether it improves outcomes enough to warrant the added resource use.
Implications for practice, policy, and research
For clinical practice
Surgeons counseling older adults with groin hernias can reasonably state that the long-term chance of needing another operation for recurrence is low with all three approaches. If minimally invasive surgery is appropriate and local expertise is strong, laparoscopic repair appears to offer the most favorable recurrence profile in this study. Robotic repair may still be chosen for surgeon ergonomics or technical preference, but current evidence does not support claiming a recurrence benefit.
For hospitals and payers
Hospitals expanding robotic programs should be careful not to assume that platform adoption alone confers superior outcomes in common low-recurrence operations. Cost analyses, episode-based value assessments, and quality-of-life studies are especially important in this space. If recurrence differences are small, a higher-cost approach would need to demonstrate offsetting gains in pain, recovery, complications, or workflow efficiency to justify broader use.
For future research
Several research priorities follow from this study. First, comparative effectiveness studies should incorporate patient-reported outcomes, especially chronic groin pain and functional recovery. Second, cost-effectiveness analyses are needed in real-world practice, ideally including operating room time, disposables, capital depreciation, and downstream healthcare use. Third, studies should better characterize surgeon experience, learning curves, and hospital volume, as these may modify recurrence outcomes substantially. Finally, younger and more diverse populations should be examined to test whether these Medicare findings hold across the broader population undergoing groin hernia repair.
Conclusion
This large Medicare cohort study found that long-term operative recurrence after groin hernia repair was uncommon across robotic-assisted, laparoscopic, and open approaches. Among the three, laparoscopic repair had the lowest risk-adjusted 5-year cumulative incidence and a significantly lower hazard of operative recurrence than open repair. Robotic-assisted repair increased rapidly over time but did not show a clear recurrence advantage and had the highest cumulative recurrence estimate.
The practical message is not that robotic groin hernia repair should be abandoned, but that its expanding use should be justified by evidence broader than enthusiasm for new technology. In a procedure where recurrence rates are low across all techniques, value will likely be defined less by recurrence alone and more by patient recovery, pain outcomes, complications, surgeon expertise, and cost.
Funding and trial registration
The abstract provided does not report funding information. No ClinicalTrials.gov registration number is expected for this retrospective administrative claims cohort study, and none is reported in the provided citation details.
Citation and references
Niba VS, Howard RA, Thumma J, Norton EC, Dimick JB, Sheetz K. Surgical Approach and Long-Term Operative Recurrence Following Groin Hernia Repair. JAMA Surgery. 2026-04-29. PMID: 42054012. URL: https://pubmed.ncbi.nlm.nih.gov/42054012/
The HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1-165. PubMed-indexed guideline.
Update of the international HerniaSurge guidelines for groin hernia management. BJS Open. 2023;7(5):zrad080. PubMed-indexed update.
