Background: Persistent controversy exists regarding the optimal approach for ventral hernia repair (VHR). Considering the concerns regarding the use of intraperitoneal mesh and the increasing use of robotic technology, transabdominal preperitoneal (TAPP) is increasingly being performed. This study aims to compare TAPP and intraperitoneal onlay mesh (IPOM) for VHR.

Methods: PubMED, Cochrane, and EMBASE databases were systematically searched from inception to April 2024, for studies on patients undergoing VHR, comparing TAPP and IPOM. Outcomes included were intraoperative complications, such as vascular and bowel injury, and postoperative complications (hernia recurrence within 1 year of operation, seroma, hematoma, ileus, urinary retention, small bowel obstruction). Additional outcomes were hospital length of stay (LOS), operative time, and visual analog scale (VAS) scores after 24 h of surgery.

Results: From 398 records, 8 were included in our pooled analysis, which comprised 7 retrospective cohorts and 1 prospective cohort, totaling 952 patients. 458 (48%) patients underwent laparoscopic VHR and 494 (52%) underwent robotic VHR. Our meta-analysis revealed that TAPP is associated with a lower incidence of overall postoperative complications as a composite outcome (13.9% vs 23.9%; RR 0.66; 95% CI 0.48, 0.92; P = 0.013). After performing a subgroup analysis for robotic surgeries only, we found that TAPP also has a lower rate of urinary retention (RR 0.12; 95% CI 0.02, 0.99; P = 0.049) and hematoma compared to IPOM (RR 0.20; 95% CI 0.04, 0.95; P = 0.043). No differences were seen between both techniques regarding ileus, hernia recurrence, operative time, seroma, small bowel obstruction, vascular injury, and bowel injury. Subgroup analysis for robotic VHR showed similar results. After performing a leave-one-out sensitivity analysis, we also obtained a shorter hospital LOS (MD - 0.56 days; 95% CI - 0.86, - 0.25; p < 0.05) and VAS scores within 24 h of surgery (MD - 1.04; 95% CI - 1.61, - 0.47; p < 0.05) for the TAPP technique.

Conclusions: IPOM is associated with a higher incidence of hematoma, urinary retention, overall early postoperative complications, and potentially longer hospital LOS and higher VAS pain scores within 24 h compared to TAPP. Therefore, the TAPP should be the technique of choice for minimally invasive VHR when feasible; however, considering the availability of resources and surgeon expertise, IPOM might still be considered a viable alternative.