Robotic-assisted ventral hernia repair: a multicenter evaluation of clinical outcomes

Five years of robot-assisted ventral hernia repair: initial experience and surgical outcome

OBJECTIVE

Robot-assisted ventral hernia repair (RVHR) has become a feasible alternative for open ventral hernia repair showing fewer postoperative complications and satisfying short-term results. However, long-term results are scarce in current literature.

METHODS

All consecutive patients who underwent robot-assisted surgery for ventral hernias from June 2018 until February 2023 were included. Patient records were retrospectively reviewed for indication, need for conversion, length of stay (LOS), postoperative complications, and postoperative pain.In addition, long-term (>24 months) results (recurrence, chronic pain, and esthetic satisfaction) were assessed by phone questionnaire.

RESULTS

In total, 177 patients underwent a robot-assisted ventral hernia repair. Indication for surgery was incisional hernia (N = 109) and primary hernia (N = 68), including 124 cases with abdominal rectus diastasis. A TransAbdominal Retromuscular Umbilical Prosthesis (TARUP) was performed in 138 patients. Robotic Transversus Abdominis Release (TAR) and Extended Totally Extraperitoneal Repair (eTEP) were performed in 20 (11%) and 9 (5%) cases, respectively.Median LOS was 2 days for TARUP and 3.5 days for TAR. Minor complications occurred in 22 patients (16 TARUP, 5 TAR, 1 eTEP). The average pain score on the first postoperative day was 1.8/10. No risk factors for morbidity could be identified by uni- and multivariable analysis.Hernia recurrence developed in four (2%) patients. Chronic pain was reported in two (1%) cases. Seven (4%) patients had esthetic complaints.

CONCLUSION

Robot-assisted ventral hernia repair is a safe procedure with low postoperative pain and short LOS. Long-term results including recurrence and chronic pain are satisfying.

Laparoscopic intra-peritoneal onlay mesh plus versus robotic transabdominal pre-peritoneal for primary ventral hernias: Our technique and outcomes

INTRODUCTION

Intra-peritoneal onlay mesh repair (IPOM) still remains the most common approach for laparoscopic repair of small to medium sized hernias worldwide. In this study, we compare our early outcomes of an established procedure, i.e. laparoscopic IPOM plus to robotic transabdominal pre-peritoneal (rTAPP) for small to medium sized primary ventral hernia. To compare laparoscopic IPOM plus with rTAPP in terms of pain score, time to ambulate, hospital stay, time to return to work as well as the expenses.

PATIENTS AND METHODS

This is a retrospective analysis of prospectively collected data at our centre between July 2021 and June 2022. Operative time including docking time was recorded. Cost analysis was done in both set of patients. Pain scores were assessed using Visual Analogue Scale (VAS) at regular intervals for up to 3 months and then at the end of 1 year. Time to ambulate, return of bowel function and return to work were documented. Any complication or recurrence during the study period was recorded.

RESULTS

Mean operative time for IPOM plus and rTAPP groups was 59.00 and 73.55 min, respectively. Mean pain score for IPOM at 6, 12 and 24 h was 7.35, 6.81 and 5.77, while for rTAPP, it was 4.73, 3 and 2.55, respectively. VAS scores at 1 week, 1 month and 3 month also showed similar trends. Mean time to ambulate in minutes for IPOM and rTAPP group was 357.69 and 223.64, respectively. Mean hospital stay in days for IPOM and rTAPP was 2.12 and 1.18, respectively. Mean time to return to work in days was 11.77 and 8.45 for IPOM and rTAPP groups, respectively. Expenditure wise, cost of TAPP was more and statistically significant, owing to the use of robotic platform. The mean overall cost of laparoscopic IPOM plus and rTAPP in rupees was 187,177.69 and 245,174.55, respectively.

CONCLUSION

Robotic TAPP appears an excellent alternative to laparoscopic IPOM plus. Larger studies with long-term follow-up data are further required to reinforce it.

Initial experience of SSI Mantra robot-assisted Transabdominal pre-peritoneal repair of primary ventral hernias

INTRODUCTION

Small and medium sized primary midline ventral hernias are best treated by pre-peritoneal mesh placement. This helps in prevention of complications related to intra-peritoneal mesh placement. The challenges we face while performing laparoscopic transabdominal pre-peritoneal (TAPP) procedure can be overcome by robot-assisted TAPP (rTAPP), and we present our initial experience with the same. We describe the surgical technique used in rTAPP using the relatively new SSI Mantra platform for primary midline ventral hernia repair and evaluate its feasibility and present the outcomes.

PATIENTS AND METHODS

we performed rTAPP for primary midline ventral hernia repair in 10 patients from July 2023 to September 2023. Demographic patient data, hernia characteristics and peri-operative outcomes were measured.

RESULTS

A total of 10 patients underwent elective rTAPP for primary midline ventral hernia, of which 7 were male and 3 were female. The average defect size was 3.2 cm. The average operative time was 113 min. All the patients were discharged within 24-36 h after the procedure. There were no deaths. No post-operative complications such as haematoma, clinically significant seroma, deep or superficial wound infection or recurrence were noted within 30 days.

CONCLUSION

rTAPP is a technically feasible procedure for the repair of small- and medium-sized midline ventral hernias with defect sizes up to 5 cm. SSI Mantra robotic platform provides the same benefit that other conventional robotic platforms provide at a much lesser cost. Further studies looking at the cost-benefit ratio are required to substantiate the above.

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Hospital costs of robotic-assisted and open treatment of large ventral hernias

Robotic-assisted treatment of ventral hernia offers many advantages, however, studies reported higher costs for robotic surgery compared to other surgical techniques. We aimed at comparing hospital costs in patients undergoing large ventral hernia repair with either robotic or open surgery. We searched from a prospectively maintained database patients who underwent robotic or open surgery for the treatment of the large ventral hernias from January 2016 to December 2022. The primary endpoint was to assess costs in both groups. For eligible patients, data was extracted and analyzed using a propensity score-matching. Sixty-seven patients were retrieved from our database. Thirty-four underwent robotic-assisted surgery and 33 open surgery. Mean age was 66.4 ± 4.1 years, 50% of patients were male. After a propensity score-matching, a similar total cost of EUR 18,297 ± 8,435 vs. 18,024 ± 7514 (p = 0.913) in robotic-assisted and open surgery groups was noted. Direct and indirect costs were similar in both groups. Robotic surgery showed higher operatory theatre-related costs (EUR 7532 ± 2,091 vs. 3351 ± 1872, p < 0.001), which were compensated by shorter hospital stay-related costs (EUR 4265 ± 4366 vs. 7373 ± 4698, p = 0.032). In the treatment of large ventral hernia, robotic surgery had higher operatory theatre-related costs, however, they were fully compensated by shorter hospital stays and resulting in similar total costs.

Robotic-assisted versus laparoscopic incisional hernia repair: a systematic review and meta-analysis

PURPOSE

This study aimed to perform a systematic review and meta-analysis comparing the efficacy and safety outcomes of robotic-assisted and laparoscopic techniques for incisional hernia repair.

METHODS

PubMed, Embase, Scopus, Cochrane databases, and conference abstracts were systematically searched for studies that directly compared robot-assisted versus laparoscopy for incisional hernia repair and reported safety or efficacy outcomes in a follow-up of ≥ 1 month. The primary endpoints of interest were postoperative complications and the length of hospital stay.

RESULTS

The search strategy yielded 2104 results, of which four studies met the inclusion criteria. The studies included 1293 patients with incisional hernia repairs, 440 (34%) of whom underwent robot-assisted repair. Study follow-up ranged from 1 to 24 months. There was no significant difference between groups in the incidence of postoperative complications (OR 0.65; 95% CI 0.35-1.21; p = 0.17). The recurrence rate of incisional hernias (OR 0.34; 95% CI 0.05-2.29; p = 0.27) was also similar between robotic and laparoscopic surgeries. Hospital length of stay (MD - 1.05 days; 95% CI - 2.06, - 0.04; p = 0.04) was significantly reduced in the robotic-assisted repair. However, the robot-assisted repair had a significantly longer operative time (MD 69.6 min; 95% CI 59.0-80.1; p < 0.001).

CONCLUSION

The robotic approach for incisional hernia repair was associated with a significant difference between the two groups in complications and recurrence rates, a longer operative time than laparoscopic repair, but with a shorter length of stay.

Enhanced recovery after robotic ventral hernia repair: factors associated with overnight stay in hospital

PURPOSE

Enhanced recovery after surgery (ERAS) protocols lead to reduced post-operative stay and improved outcomes after most types of abdominal surgery. Little is known about the optimal post-operative protocol after robotic ventral hernia repair (RVHR), including the potential limits of outpatient surgery. We report the results of an ERAS protocol after RVHR aiming to identify factors associated with overnight stay in hospital, as well as patient-reported pain levels in the immediate post-operative period.

METHODS

This was a prospective cohort study of consecutive patients undergoing RVHR. Patients were included in a prospective database, registering patient characteristics, operative details, pain and fatigue during the first 3 post-operative days and pre- and 30-day post-operative hernia-related quality of life, using the EuraHS questionnaire.

RESULTS

A total of 109 patients were included, of which 66 (61%) underwent incisional hernia repair. The most performed procedure was TARUP (robotic transabdominal retromuscular umbilical prosthetic hernia repair) (60.6%) followed by bilateral roboTAR (robotic transversus abdominis release) (19.3%). The mean horizontal fascial defect was 4.8 cm, and the mean duration of surgery was 141 min. In total, 78 (71.6%) patients were discharged on the day of surgery, and factors associated with overnight stay were increasing fascial defect area, longer duration of surgery, and transverse abdominis release. There was no association between post-operative pain and overnight hospital stay. The mean EuraHS score decreased significantly from 38.4 to 6.4 (P < 0.001).

CONCLUSION

An ERAS protocol after RVHR was associated with a high rate of outpatient procedures with low patient-reported pain levels.

Robotic Ventral Hernia Repair and Concomitant Procedures: Mid-term Outcomes and Risk Factors Associated With Postoperative Complications

BACKGROUND

Ventral hernia remains as one of the most performed procedures worldwide. With the aging of the population and increasing comorbidities, it is common for ventral hernia to coexist with other pathologies that require surgery. Patients may opt for concomitant repairs while undergoing ventral hernia surgery. Therefore, the purpose of this study is to investigate the clinical outcomes of robotic ventral hernia repair (RVHR) in patients undergoing concomitant repairs.

MATERIALS AND METHODS

Patients who underwent RVHR with concomitant repairs over a period of 9 years were included in this retrospective study. Pre, intra, and postoperative variables including the patient's demographics, hernia characteristics, complications, and hernia recurrence were reported. Univariate analysis was performed to evaluate potential variables associated with increased risk of postoperative complications.

RESULTS

A total of 109 (33% females) patients were included in this study. Mean age and body mass index were 59.9±12.7 years and 30.5±5.7 kg/m 2 , respectively. Concomitant repairs were mostly abdominal wall procedures (inguinal hernia repairs, 88.1%). Other procedures included nonabdominal wall surgeries. Incisional hernia repairs were higher than primary repairs (55% vs 45%, respectively). Median operative time and hospital length of stay were 145 min (102 to 245) and 1 day (0 to 1), respectively. Mean postoperative follow-up was 39.2 (4.1 to 93.6) months. In total, 24 patients had postoperative complications, out of which 16 (14.7%) were Clavien-Dindo grade I and II, and 10 (9.2%) were grade III and IV. Nine patients had surgical site events, and two recurrences were recorded. Postoperative complications were associated with incisional hernias [Odds ratio (OR)=8.4; P =0.003; 95% CI=2.092-33.423], nonabdominal wall concomitant procedures (OR=5.9; P =0.013; 95% CI=1.453-24.451), and history of wound infection (OR=3.473; P =0.047; 95% CI=1.016-11.872).

CONCLUSIONS

This is the first study to report outcomes of concomitant repairs with RVHR, with notable Clavien-Dindo grade III and IV complications of 9%. Incisional hernia repairs, nonabdominal wall procedures, and a history of wound infection were risk factors for postoperative complications.

Implementation of robotic surgery in Dubai: a focus on outcomes

The rapid acceptance of robotic surgery in gallbladder, inguinal, and ventral hernia surgery has led to the growth of robotic surgery programs around the world. As this is new technology, implementation of such programs needs to be done safely, with a focus on patient outcomes. We herein describe the implementation of a new robotic surgery program in a major hospital in the Middle East. A laparoendoscopic surgeon led the program after training and proctoring. Competency based credentialing were created and put in place. To confirm safety of the program, all laparoscopic and robotic cholecystectomy and hernia operations were followed, and perioperative data analyzed. Out of the 304 patients included in this study, 157 were performed using the robotic approach. In the cholecystectomy group (n = 103) the single site approach offered shorter operative times (P < 0.05). Both the single site robotic and the robotic assisted approaches resulted in less pain (P < 0.05). In the inguinal hernia group (n = 146) the laparoscopic approach offered shorter operative times (P < 0.05), but the robotic approach was associated with less pain (P < 0.05). In the ventral hernia group (n = 55), the open approach offered the best operative times, but the robotic approach was associated with the least amount of pain (P < 0.05). This is the first report of the implementation of a robotic program in the MENA region where the primary measure of success is outcomes. We show that monitoring cholecystectomy, inguinal or ventral hernia data can confirm the quality of the program before expansion and moving forward to more complex procedures.

[Treatment of ventral hernias in patients with morbid obesity]

The review is devoted to the treatment of ventral hernias in patients with morbid obesity. This issue is important due to significant number of such patients and no unambiguous clinical recommendations. The advantages of simultaneous surgery (with bariatric intervention) are obvious, i.e. lower risk of postoperative hernia incarceration and no need for re-hospitalization with another intervention. High risk of bariatric population makes it necessary to minimize surgery time and surgical trauma. A staged approach with reducing body weight surgically or conservatively before hernia repair is often chosen. Hernia repair should be performed using laparoscopic or robotic techniques with obligatory use of mesh implants. Panniculectomy or abdominoplasty as the main surgery is a valid option. Currently, it is necessary to develop clear criteria for selecting patients with morbid obesity for staged and simultaneous treatment of ventral hernias.

Robotic versus laparoscopic ventral hernia repair: a systematic review and meta-analysis of randomised controlled trials and propensity score matched studies

PURPOSE

There has not been a consensus on the superiority of a surgical approach for minimally invasive ventral hernia repair. This systematic review and meta-analysis (SRMA) aims to compare clinical, and patient-reported outcomes of robotic-assisted ventral hernia repair (rVHR) to traditional endo-laparoscopic ventral hernia repair (lapVHR).

METHODS

We searched PubMed, EMBASE, Cochrane and Scopus from inception to 16th March 2021. We selected randomised controlled trials and propensity score matched studies comparing rVHR to lapVHR. A meta-analysis was done for the outcomes of operative time, length of hospital stay, open conversion, recurrence, surgical site occurrence and cost.

RESULTS

A total of 5 studies (3732 patients) were included in the qualitative and quantitative synthesis. Significantly shorter operative times were reported with the lapVHR as compared to rVHR (weighted mean difference (WMD): 62.52, 95% CI: 50.84-74.19). There was also significantly less rates of open conversion with rVHR as compared to lapVHR (WMD: 0.22, 95% CI: 0.09-0.54). No significant differences in patient-reported outcomes that was discernible from the two papers that reported them.

CONCLUSION

Overall, rVHR is comparable to lapVHR with longer operative times but less open conversion. It is, therefore, important to have proper patient selection to maximise the utility of rVHR.

Excess Body Weight and Abdominal Hernia

Background

Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI.

Summary

This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young.

Key Messages

Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

Robotic abdominal wall repair: adoption and early outcomes in a large academic medical center

Robotic-assisted abdominal wall repair (RAWR) has seen an exponential adoption over the last 5 years. Skepticism surrounding the safety, efficacy, and cost continues to limit a more widespread adoption of the platform. We describe our initial experience of 312 patients undergoing RAWR at a large academic center. A retrospective review of all patients undergoing any RAWR from July 1, 2016 to March 18, 2020 was completed. Patient specific, operation specific, and 30-day outcomes specific data were collected. Univariate analysis and multivariate logistic regression were used to assess factors associated with 30-day complications. There was a steady adoption of RAWR over the study period. A total of 312 patient were included, 138 (44%) were abdominal wall repairs and 174 (56%) were inguinal repairs. The mean age of the cohort was 54.2 years (SD 16), 69% were males, and the mean BMI was 29 kg/m² (SD 4.8). There were two reported intraoperative events and nine operative conversions. 60 patients had at least one complication at 30-days. These include: 52 seromas, 4 hematomas, 2 surgical-site infections, 1 deep venous thrombus, and 1 recurrence at 30-days. BMI, type of hernia, and sex were not associated with complications at 30-days. The use of absorbable mesh, longer hospital stay, operative conversion, previous repair, and expert hernia surgeon were significant predictors of 30-day complications. Age, operative conversion, and previous repair were the only predictors of 30-day complications on multivariate regression. Our initial experience of 312 patients demonstrates the adoption and comparable short-term outcomes for a wide variety of robotic-assisted hernia repairs.

Robot-assisted Treatment of Epigastric Hernias With a Suprapubic Approach

BACKGROUND

Robot-assisted ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are placed laterally to meet the distance from the fascial defect. The aim of our study is to report our experience of epigastric hernia treatment with trocar insertion in the suprapubic region.

MATERIALS AND METHODS

On a prospectively collected dataset on robot-assisted surgery, patients treated for epigastric hernias with suprapubic approach were identified. Demographic and clinical data were collected and analyzed.

RESULTS

Twelve patients were selected. Median age was 58.5 years [interquartile range (IQR): 47.8 to 67.3 y]; 4 patients were male (33.3%) and the median body mass index was 23.9 kg/m2 (IQR: 22.3 to 26.2 kg/m2). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR: 13.75 to 31.0 mm); median larger mesh diameter was 13.5 cm (IQR: 9.5 to 15.0 cm); and median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication or conversion to open surgery occurred. Postoperatively, 2 patients presented a seroma and median length of hospital stay was 2.0 days (IQR: 1.75 to 3 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 4 to 29 mo).

CONCLUSIONS

In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.

Robotic-assisted onlay technique: new approach using anterior mesh positioning in ventral hernia repair-an easy way to spread robotic surgery

There is still a lot of debate about what is the best technique for ventral hernia (VH) repair surgery. Robotic-assisted procedures are an excellent alternative to overcome the technical difficulties of regular laparoscopic surgery. The onlay technique is one of the most performed surgeries worldwide in open ventral hernia surgery, and the anatomy is easily recognized by all surgeons. Introducing the robotic onlay approach, using robotic-assisted surgery to perform ventral hernia repair with a technique is usual for most surgeons. This "new" approach may change the initial concept that minimally invasive abdominal wall surgery requires specific and tedious training and can help standardize ventral hernia repair by robotic surgery and facilitate training, allowing more surgeons to perform minimally invasive abdominal wall surgery. Finally, clinical studies are needed to measure the impact of Robotot implementation in MIS ventral hernia repair and long-term results.

Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh: The PROVE-IT Randomized Clinical Trial

Importance

Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.

Objective

To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain.

Design, Setting, and Participants

A registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.

Interventions

Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh.

Main Outcomes and Measures

The trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost.

Results

Seventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).

Conclusions and Relevance

Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.

Trial Registration

ClinicalTrials.gov Identifier: NCT03283982.

Prospective observational study of abdominal wall reconstruction with THT technique in primary midline defects with diastasis recti: clinical and functional outcomes in 110 consecutive patients

INTRODUCTION

Surgical treatment of diastasis recti is still a matter of debate. Open approaches such as abdominoplasty, which offer the possibility to combine reparation of the diastasis with abdominal cosmetic surgery, are challenged by the emerging less-invasive laparoscopic or robotic techniques that offer shorter recovery for patients. However, evidence in favour of one of the two approaches concerning both short- and long-term complications and functional results is still lacking. In this paper, we analysed clinical and functional results of a new endo-laparoscopic technique for midline reconstruction (THT technique) in patients with primary abdominal wall defects associated with diastasis recti.

METHODS

Prospective observational study on 110 consecutive patients was submitted to endo-laparoscopic reconstruction of the abdominal wall with linear staplers. Morbidity and relapse rates with clinical and radiological follow-up were recorded at 1, 6, 12, and 24 months after the operation. Data regarding the impact of surgery on patients' quality of life (EuraHSQol) on chronic low back pain (Oswestry Disability Index, ODI) and urinary stress incontinence (Incontinence Severity Index, ISI) were gathered.

RESULTS

After a mean follow-up of 14 months, the morbidity rate was 9.1% and no recurrences were recorded. 6-month follow-up ultrasound showed a rectus muscles mean distance of 6.7 mm; EuraHSQol, ODI, and ISI scores significantly improved in 93%, 77%, and 63% of the cases, respectively.

CONCLUSIONS

The THT technique proved to be a feasible, safe, and effective alternative for corrective surgery of primary midline hernias associated with diastasis recti. Short- and mid-term results are encouraging but need to be confirmed by further studies with longer follow-up. The achieved midline reconstruction offers a significant improvement of patients' perceived quality of life through reduction of abdominal wall pain, bulging, low back pain, and urinary stress incontinence.

Hybrid robotic transversus abdominis release versus open: propensity-matched analysis of 30-day outcomes

PURPOSE

To examine the hospital length of stay (LOS) and 30 day outcomes of hybrid robotic transversus abdominis release (hrTAR) compared with open transversus abdominis release (oTAR).

METHODS

Patients receiving hrTAR were selected from the AHSQC database and propensity matched with a contemporary cohort of oTAR patients.

RESULTS

The cohort included 95 hrTAR and 285 oTAR patients. There was a significantly shorter median LOS in the hrTAR cohort (3 vs. 5 days, p < 0.001). The rate of surgical site occurrences in the hrTAR cohort was also lower than for oTAR (5% vs. 15%, p = 0.015). Readmission rates were not different between hrTAR and oTAR (6% vs. 8%, p = 0.65).

CONCLUSION

hrTAR demonstrates improved LOS compared to oTAR as well as fewer surgical site related occurrences. Further studies are needed to investigate the etiology behind the improved LOS and to confirm appropriate long-term outcomes from hybrid robotic TAR.

Robotic-assisted and laparoscopic hernia repair: real-world evidence from the Americas Hernia Society Quality Collaborative (AHSQC)

BACKGROUND

Ventral hernia repair (VHR) is a commonly performed procedure and is especially prevalent in patients who have undergone previous open abdominal surgery: up to 28% of patients who have undergone laparotomy will develop a ventral hernia. There is increasing interest in robotic-assisted VHR (RVHR) as a minimally invasive approach to VHR not requiring myofascial release and in RVHR outcomes relative to outcomes associated with laparoscopic VHR (LVHR). We hypothesized real-world evidence from the Americas Hernia Society Quality Collaborative (AHSQC) database will indicate comparable clinical outcomes from RVHR and LVHR approaches not employing myofascial release.

METHODS

Retrospective, comparative analysis of prospectively collected data describing laparoscopic and robotic-assisted elective ventral hernia repair procedures reported in the multi-institutional AHSQC database. A one-to-one propensity score matching algorithm identified comparable groups of patients to adjust for potential selection bias that could result from surgeon choice of repair approach.

RESULTS

Matched data describe preoperative characteristics and perioperative outcomes in 615 patients in each group. The following significant differences were observed among the 11 outcomes that were pre-specified. Operative time tended to be longer for the RVHR group compared to the LVHR group (p < 0.001). Length of stay differed between the two groups; while both groups had a median length of stay of 0, stay lengths tended to be longer in the LVHR group (p < 0.001). Rates of conversion to laparotomy were fewer for the RVHR group: < 1% and 2%, respectively (p = 0.007). Through 30 days, there were fewer RVHR patient-clinic visits (p = 0.038).

CONCLUSION

Both RVHR and LVHR perioperative results compare favorably with each other in most measures. Differences favored RVHR in terms of shorter LOS, fewer conversions to laparotomy, and fewer postoperative clinic visits; differences favored LVHR in terms of shorter operative times.

Robotic-Assisted Laparoscopic Ventral Hernia Repair

Robotic-assisted laparoscopic ventral hernia repair (RA-LVHR) has many options. Before applying these techniques, it is important to identify the patient's goals for hernia repair, align yourself with those goals, and apply a technique appropriate for the clinical scenario, and most likely to meet the goals. Fundamental principles of hernia repair must be maintained: avoiding thermal injury to hollow viscera, adequate dissection of abdominal wall, appropriate mesh:defect ratio, stronger fixation where overlap is limited, and more overlap where fixation points are weak. This manuscript will detail available techniques for RA-LVHR along with their their advantages and disadvantages.

Robotic-assisted ventral and incisional hernia repair with hernia defect closure and intraperitoneal onlay mesh (IPOM) experience

BACKGROUND

The most common technique described for robotic ventral hernia repair (RVHR) is intraperitoneal onlay mesh (IPOM). With the evolution of robotics, advanced techniques including retro rectus mesh reinforcement, and component separation are being popularized. However, these procedures require more dissection, and longer operative times. In this study we reviewed our experience with robotic ventral/incisional hernia repair (RVHR) with hernia defect closure (HDC) and IPOM.

METHODS

Retrospective chart review and follow-up of 31 consecutive cases of ventral/incisional hernia treated between August 2011 and December 2018. Demographics, operative times, blood loss, length of stay (LOS), hernia size, location, and type, mesh size and type, recurrence, conversion to open ventral hernia repair (OVHR) and complications including bleeding, seroma formation and infection were analyzed.

RESULTS

Mean age was 63.9 years old, with median BMI of 31.24 kg/m². Median hernia area was 17 cm². Mean operating time was 142.61 min (SD 59.79). Mean LOS was 1.46 days (range 1-5), with 48% being outpatient, and overnight stay in 32% for pain control. Conversion was necessary in 12.9% cases. Complication rate was 3% for enterotomy. Recurrence was 14.81% after a mean follow-up of 26.96 months. There was significant association of recurrence with COPD history (P = 0.0215) and multiple hernia defects (P = 0.0376).

CONCLUSION

Our recurrence rate (14.81%) compares favorably to those reported in literature (16.7%) for LVHR with HDC and IPOM. Our experience also indicates that IPOM is associated with satisfactory outcomes, low conversion and complications rates, and short LOS.

Robotic assistance in ventral hernia repair may decrease the incidence of hernia recurrence

Background:

Since the advent of laparoscopic surgery, many studies have shown the advantages of laparoscopic surgery over open surgery for ventral hernia repair (VHR). As robotic surgery is gaining popularity, we sought to compare the outcomes of this newer robotic-assisted technique to the outcomes of established open and laparoscopic techniques to assess for any additional benefit.

Methods:

A meta-analysis research design was employed. Multiple databases were queried for publications over the past 10 years and 23 articles were selected based on pre-determined selection criteria. Data were extracted and the arm-based network meta-analysis method was utilised to examine the effect difference for the three arms of our study: Open, laparoscopic and robotic-assisted VHR.

Results:

As expected, laparoscopy had an advantage over open VHR in terms of infection rates. This advantage was also observed in the robotic group over the open group; however, there was no statistical difference between the laparoscopic and robotic groups when infection rates were compared head-to-head. The robotic group had a significant advantage over both the open and more importantly, the laparoscopic groups in recurrence rates.

Conclusions:

The results of this study suggest that robotic surgery maintains some of the advantages of laparoscopic surgery and may also provide the additional advantage of recurrence rate reduction. This may be explained by the ability to perform a more complex hernia repair with robotic assistance secondary to the ease of closure of the fascial defect. More research is needed to validate this finding.

Robotic ventral hernia repair: a safe and durable approach

BACKGROUND

Short-term success following robotic-assisted ventral hernia repair (RVHR) is well established; however, data describing outcomes after the first year are limited. In this study, we followed a cohort of patients with an average of 1.8 years of follow-up to demonstrate the durability of this technique and examine risk factors for recurrence.

METHODS

A retrospective analysis of RVHR performed by a single surgeon from 2012 to 2016 was done. The technical approach for hernia repair consisted of tension-free primary fascial closure with placement of preperitoneal mesh when possible. The primary end point of hernia recurrence was determined based on physical examination or imaging documented in the medical record. A logistic regression model was used to identify patient risk factors for recurrence.

RESULTS

One hundred and eight RVHRs were performed over 4 years. Mean age was 52.72 ± 13.61 years, BMI was 33.07 ± 7.82 kg/m², and hernia defect size was 70.1 ± 86.3 cm². In terms of patient characteristics, 17.6% of patients were diabetic, 13.9% were smokers preoperatively, 72.2% were ASA class 3 or higher, and 29.6% had prior VHR. Primary fascial closure was achieved in all RVHRs, with 23.1% requiring component separation. Mesh was used in 97.2% of patients: 79.5% had preperitoneal mesh and 17.6% had intraperitoneal onlay mesh. Ninety-eight percent of patients had long-term follow-up at a mean of 625.6 days. Recurrence rate was 12%, with one recurrence attributed to an inguinal hernia fixed concurrently with a midline defect. There were no statistically significant differences in gender, age, BMI, ASA class, incidence of diabetes, smoking status, or number of previous hernia repairs. Hernia defect size and perioperative complications including SSO, ileus, obstruction, or any other medical complication were not predictive of recurrence. Technical approach did not affect outcomes.

CONCLUSION

RVHR is safe and durable with a low recurrence rate at a mean of 21 months postoperatively. Patient characteristics or type of repair were not predictive of recurrence.

Design of a comparative outcome analysis of open, laparoscopic, or robotic-assisted incisional or inguinal hernia repair utilizing surgeon experience and a novel follow-up model

BACKGROUND

In a recent publication, the International Guidelines for Groin Hernia Management by the European Hernia Society (EHS) recognized the need to individualize and tailor the surgical approach for hernia repair. There may be different opportunities for optimization of the surgical technique for surgeons performing open, laparoscopic, or robotic-assisted hernia repair. Robotic-assisted hernia repair is a relatively new minimally invasive surgical approach compared to laparoscopic and open repair. Currently, there is a lack of comparative prospective studies designed to evaluate long-term outcomes of patients undergoing robotic-assisted, laparoscopic, or open hernia repair.

MATERIALS & METHODS

This manuscript presents an innovative study design with two study cohorts (incisional and inguinal hernia repair) that contain three arms (robotic-assisted, laparoscopic, and open). The trial objective is to collect short-term and long-term outcomes for patients undergoing robotic-assisted, laparoscopic, or open hernia repair. The present publication will discuss the trial design, methods used to ensure consistency in surgeon expertise, and provides strategies to obtain long-term (> 3 months) follow-up data for enrolled patients.

RESULTS

One hundred subjects underwent incisional and one hundred underwent inguinal hernia repair at the time of this manuscript. Surgeon experience was analyzed across the three surgical techniques and follow-up compliance was assessed through 1 year. The follow-up completion rates for both study cohorts were >80% for all visits.

CONCLUSIONS

The innovative trial design helped to improve the quality and quantity of long-term follow-up. More innovative options to improve patient retention may be tested in future trials of similar design.

Robotic ventral hernia repair in morbidly obese patients: perioperative and mid-term outcomes

BACKGROUND

Obesity is a growing epidemic and it has been found to be an independent risk factor for a multitude of perioperative complications. We describe our experience with morbidly obese patients who underwent robotic ventral hernia repair (RVHR), examining factors affecting perioperative and mid-term outcomes.

METHODS

From a prospectively maintained database, all morbid obese (BMI ≥ 40 kg/m²) patients who underwent robotic procedures between 2013 and 2018 were analyzed retrospectively including perioperative outcomes and the mid-term follow-up. Complications were assessed with validated grading systems and index. Univariate analyses and multivariate logistic regression analysis were performed to determine the factors associated with the development of any complication. Kaplan-Meier's time-to-event analysis was performed to calculate freedom-of-recurrence.

RESULTS

Fifty patients with median BMI 42.9 kg/m² were included. The median last pain score before leaving PACU was 4. The mean LOS of all cohorts was 0.32 day. The postoperative complication rate was 46%. The most frequent complication was persistent pain/discomfort (32%) in early postoperative period. Minor complications (Clavien-Dindo grade-I and II) were seen in 40% of patients while major complications (Clavien-Dindo grade-III and IV) were seen in 6%. The maximum comprehensive complication index® score was 42.9. In regression analysis, BMI, adhesiolysis, intraperitoneal mesh placement, and off-console time were found to be significantly associated with postoperative complications. Mean follow-up was 22.7 months. Hernia recurrence was seen in 2% and the mean freedom-of-recurrence was 57.4 months (95% CI 54.6-60.2).

CONCLUSIONS

To our best knowledge, this study is the first to present outcomes of morbidly obese patients who underwent RVHR. The results indicate the safety and efficacy of RVHR in morbid obesity with a low recurrence rate as well as a long freedom-of-recurrence time. Further studies are needed to better elucidate the role of robotic surgery in morbidly obese patients.

Hernia umbilical: un problema no resuelto

La cirugía de la hernia umbilical ha sido considerada tradicionalmente como sencilla y de fácil ejecución. El cambio conceptual de la hernia umbilical y los avances en su tratamiento han modificado su abordaje, estableciéndose escenarios de complejidad variable (obesidad, embarazo, cirróticos, distasis de los rectos, etc.) que demandan un conocimiento más profundo del tema por parte de la comunidad médica. El impacto económico en el sistema de salud, debido a su alta prevalencia como patología quirúrgica, implica un uso racional de recursos, así como la necesidad de una nueva categorización dentro de la cirugía de la pared abdominal. Es necesario establecer modificaciones en los procesos diagnósticos y terapéuticos en una entidad que ha sido relegada a los niveles básicos del ejercicio quirúrgico habitual.

Short-term comparison between preperitoneal and intraperitoneal onlay mesh placement in robotic ventral hernia repair

PURPOSE

The aim of this study was to compare perioperative results of robotic IPOM (r-IPOM) and robotic TAPP (r-TAPP) in ventral hernia repair, and to identify risk factors associated with postoperative complications.

METHODS

After obtaining balanced groups with propensity score matching, the comparative analysis was performed in terms of perioperative and early outcomes. All variables were also examined in a subset analysis in patients with and without complications. Multivariable regression analysis was used to identify independent risk factors associated with the development of complications.

RESULTS

Of 305 r-IPOM and r-TAPP procedures, 104 patients were assigned to each group after propensity score matching. There was no difference in operative times between two groups. Although postoperative complications were largely minor (Clavien-Dindo grade-I and II), the rate of complications was higher in the r-IPOM group within the first 3-weeks (33.3% in r-IPOM vs. 20% in r-TAPP, p = 0.039). At the 3-month visit, outcomes between groups were not different (p = 0.413). Emergency department re-visits within 30-days and surgical site events were also higher in the IPOM group (p = 0.028, p = 0.042, respectively). In regression analysis, the development of complications was associated with incisional hernias (p = 0.040), intraperitoneal mesh position (p = 0.046) and longer procedure duration (p = 0.049).

CONCLUSION

Our data suggest r-IPOM may be associated with increased complication rates in the immediate postoperative period when compared to r-TAPP. However, at 3 months, outcomes are comparable. More investigation is needed in this area, specifically with regards to long-term follow-up and multicenter data, to determine the true value of extra-peritoneal mesh placement.

Laparoscopic ventral hernia repair with intraperitoneal onlay mesh-results from a general surgical unit

BACKGROUND

Symptomatic ventral herniation is a common clinical presentation. The treatment, whether elective or as an emergency, can be difficult and a variety of surgical repairs are utilised. Intraperitoneal onlay mesh (IPOM) involves the placement of a reinforcing prosthesis, usually supported by primary closure of the defect. Intra-abdominal adhesions have been highlighted as a potential complication in utilising this form of mesh placement. Several methods of laparoscopic mesh placement outside of the peritoneal cavity are gaining prominence as potential alternatives to IPOM.

AIMS

This study reviews our experience with IPOM in the repair of ventral hernia by a single surgical team.

METHODS

A prospectively maintained electronic database of all laparoscopic ventral hernia repair (LVHR) performed within the study period was analysed and reported. Follow-up questionnaires were sent to patients to follow long-term outcomes.

RESULTS

One hundred eight patients underwent LVHR over a 7-year period. Demographics demonstrated an obese patient group (BMI 30.89 ± 4.9 kg/m²), with a variety of hernia sizes and morphologies. Hernia recurrence was found in two patients (1.8%). Twenty-nine (26.8%) patients suffered a complication, but only eight (7.4%) of those required intervention beyond pharmacotherapy. Two patients required mesh explantation.

CONCLUSIONS

IPOM for the general surgeon is a relatively safe and effective method of repairing ventral hernias, with a low recurrence rate.

Ascending the Learning Curve of Robotic Abdominal Wall Reconstruction

Background:

Robotic complex abdominal wall reconstruction (r-AWR) using transversus abdominis release (TAR) is associated with decreased wound complications, morbidity, and length of stay compared with open repair. This report describes a single-institution experience of r-AWR.

Methods:

A retrospective chart review was performed on patients who underwent r-AWR by a single surgeon (D.H.) from August 2015 through October 2018.

Results:

Fifty-five patients underwent r-AWR (16 males [29%] and 39 females [71%]) with a mean age of 60.2 (range 33 to 87) years and a mean body mass index of 34.6 (range 23 to 54) kg/m². Forty-one patients presented with an initial ventral hernia (74.5%) and 14 with a recurrent hernia (25.5%). Five patients had a grade 1 hernia (9.1%), 46 had a grade 2 hernia (83.6%), and 4 had a grade 3 hernia (7.3%) according to the Ventral Hernia Working Group system. Thirty-four (62%) patients underwent TAR, 21 (38%) patients underwent bilateral retrorectus release, and 10 (18.2%) patients underwent concomitant inguinal hernia repair. Mean operative time with TAR was 294 (range 106 to 472) minutes and 183 (range 126 to 254) minutes without TAR. Mean length of stay was 1.5 (range 0 to 10) days. Mean follow-up was 10.7 (range 1 to 52) weeks with no hernia recurrences. Seromas occurred in 6 (10.9%) patients, with 2 (3.6%) requiring drainage. Two (3.6%) 30-day readmissions occurred with no conversions to open or 30-day mortalities.

Conclusions:

r-AWR with and without TAR is a safe and feasible procedure associated with a short LOS, low complication rate, and low recurrence even within the surgeon's learning curve experience.

Reducing Length of Stay Using a Robotic-assisted Approach for Retromuscular Ventral Hernia Repair: A Comparative Analysis From the Americas Hernia Society Quality Collaborative

OBJECTIVE

The aim of this study was to compare length of stay (LOS) after robotic-assisted and open retromuscular ventral hernia repair (RVHR).

BACKGROUND

RVHR has traditionally been performed by open techniques. Robotic-assisted surgery enables surgeons to perform minimally invasive RVHR, but with unknown benefit. Using real-world evidence, this study compared LOS after open (o-RVHR) and robotic-assisted (r-RVHR) approach.

METHODS

Multi-institutional data from patients undergoing elective RVHR in the Americas Hernia Society Quality Collaborative between 2013 and 2016 were analyzed. Propensity score matching was used to compare median LOS between o-RVHR and r-RVHR groups. This work was supported by an unrestricted grant from Intuitive Surgical, and all clinical authors have declared direct or indirect relationships with Intuitive Surgical.

RESULTS

In all, 333 patients met inclusion criteria for a 2:1 match performed on 111 r-RVHR patients using propensity scores, with 222 o-RVHR patients having similar characteristics as the robotic-assisted group. Median LOS [interquartile range (IQR)] was significantly decreased for r-RVHR patients [2 days (IQR 2)] compared with o-RVHR patients [3 days (IQR 3), P < 0.001]. No differences in 30-day readmissions or surgical site infections were observed. Higher surgical site occurrences were noted with r-RVHR, consisting mostly of seromas not requiring intervention.

CONCLUSIONS

Using real-world evidence, a robotic-assisted approach to RVHR offers the clinical benefit of reduced postoperative LOS. Ongoing monitoring of this technique should be employed through continuous quality improvement to determine the long-term effect on hernia recurrence, complications, patient satisfaction, and overall cost.

Robotic TAPP Ventral Hernia Repair: Early Lessons Learned at an Inner City Safety Net Hospital

Background and Objectives

Ventral hernia repair is one of the most commonly performed general surgery procedures, and minimally invasive approaches are increasingly preferred. The physiologic repair offered by the preperitoneal approach is favorable, with reduced complications, but it remains a technical challenge. The robotic platform allows for enhanced instrument flexibility and ease of operation. We conducted a retrospective review of our experience with robotic transabdominal preperitoneal repair (rTAPP) versus robotic intraperitoneal onlay mesh (rIPOM) at a tertiary care hospital in an urban setting.

Methods

We reviewed the records of patients undergoing minimally invasive ventral hernia repair from March 2014 through March 2017. Demographics, complication rates, and operative time were compared by t test and Chi square test, as applicable.

Results

Sixty-three patients met the criteria for inclusion in the study. Of those, 27 underwent ventral hernia repair with rIPOM and 36 with rTAPP, with no major intraoperative complications. There were no significant differences in demographics between the 2 groups in age, BMI, and sex. The difference in mean operative time was not significant (rIPOM 167.26 [SD 51.76] minutes vs rTAPP 158.84 minutes [SD 61.5]; P = .57), whereas mean console time was significantly different (rIPOM 70.88 minutes [SD 32.88] vs rTAPP 90.26 [SD 31.17]; P = .018). Postoperative complications occurred only with rIPOM and included urinary retention, seroma, and fever.

Conclusions

rTAPP is a promising alternative to rIPOM, with reduced complications without adding significant operative time, and may allow for reduced costs.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results

PURPOSE

The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR.

METHODS

This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain.

RESULTS

Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm³, p = 0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019).

CONCLUSION

Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions.

CLINICAL TRIAL NUMBER

NCT02542085.

Robotic ventral hernia repair is not superior to laparoscopic: a national database review

BACKGROUND

Minimally invasive surgery (MIS) use for ventral hernia repair has increased over the last decade. Whether outcomes are improved by robotic assistance remains a subject of debate. The aim of this study is to evaluate outcomes (including cost, complications, length of stay (LOS), and pain medication utilization) in patients who underwent an open (OVHR), laparoscopic (LVHR), or robotic (RVHR) ventral hernia repair (VHR).

METHODS

The Vizient database was queried using ICD-9 procedure and diagnosis codes for patients who underwent VHR from January 2013 to September 2015. Complications, 30-day readmission, mortality, LOS, cost, and intra-hospital opiate utilization were analyzed using IBM SPSS v.23.0.0.0. Median tests with post hoc pairwise comparisons, Fischer's exact, and Pearson's chi-squared test with Bonferroni correction were applied where appropriate, with α = 0.05.

RESULTS

46,799 patients (OVHR: N = 39,505, LVHR: N = 6829, RVHR: N = 465) met the criteria and patients in each group had similar demographics (Table 1). OVHR was associated with significant increased overall complications, 30-day readmission, LOS, and postoperative pain use compared to RVHR or LVHR. OVHR had higher mortality and postoperative infection rates than LVHR. RVHR had significantly higher rates of complications and postoperative infections compared to LVHR, although there was no difference in mortality, 30-day readmission, LOS, and postoperative pain medication use. Mean direct cost of surgery was significantly higher for RVHR, followed by OVHR and LVHR.

CONCLUSIONS

Overall patient outcomes were improved in the LVHR and RVHR groups compared to the open approach. However, RVHR patients did not have significant improvement compared with the LVHR group in either short-term outcomes or opiate medication used. While RVHR surgery was the most expensive modality, OVHR was also significantly costlier than LVHR, which was the least expensive. Long-term data on recurrence could not be evaluated and should be studied to determine the role of robotic surgery in VHR and recurrence rates.

A nationwide evaluation of robotic ventral hernia surgery

BACKGROUND

The purpose of this study was to examine outcomes of robotic ventral hernia repair(RVHR) versus laparoscopic ventral hernia repair(LVHR).

METHODS

The Nationwide Inpatient Sample was queried from October 2008 to December 2013 for ventral hernia repairs. Demographics, morbidity, mortality, and charges were compared between RVHR and LVHR.

RESULTS

From 2008-2013, 149,622 ventral hernia surgeries were identified; 117,028 open, 32,243 laparoscopic, and 351 robotic. Open repairs were excluded. RVHR rose annually with 2013 containing 47.9% of all RVHRs. RVHR patients were more likely to be older and have more chronic conditions. There was no difference between length of stay. Pneumonia rates were higher with RVHR; however, after controlling for confounding variables, there was no difference in pneumonia rates. Mortality and other major complications were similar. Total charges were increased for RVHR in univariate and multivariate analysis. RVHR was more common in teaching hospitals and wealthier zip codes.

CONCLUSION

RVHR demonstrates comparable safety to the laparoscopic technique, with increased charges and increased volume in urban teaching hospitals and patients from areas of higher median income.

Comparative analysis of perioperative outcomes of robotic versus open transversus abdominis release

BACKGROUND

Transversus abdominis release (TAR) has evolved as an effective approach to complex abdominal wall reconstructions. Although the role of robotics in hernia surgery is rapidly expanding, the benefits of a robotic approach for abdominal wall reconstruction have not been established well. We aimed to compare the impact of the application of robotics to the TAR procedure on the perioperative outcomes when compared to the open TAR repairs.

METHODS

Case-matched comparison of patients undergoing robotic TAR (R-TAR) at two specialized hernia centers to a matched historic cohort of open TAR (O-TAR) patients was performed. Outcome measures included patient demographics, operative details, postoperative complications, and length of hospitalization.

RESULTS

38 consecutive patients undergoing R-TAR were compared to 76 matched O-TAR. Patient demographics were similar between the groups, but ASA III status was more prevalent in the O-TAR group. The average operative time was significantly longer in the R-TAR group (299 ± 95 vs.. 211 ± 63 min, p < 0.001) and blood loss was significantly lower for the R-TAR group (49 ± 60 vs. 139 ± 149 mL, p < 0.001). Wound morbidity was minimal in the R-TAR, but the rate of surgical site events and surgical site infection was not different between groups. Systemic complications were significantly less frequent in the R-TAR group (0 vs. 17.1%, p = 0.026). The length of hospitalization was significantly reduced in the R-TAR group (1.3 ± 1.3 vs. 6.0 ± 3.4 days, p < 0.001).

CONCLUSIONS

In our early experience, robotic TAR was associated with longer operative times. However, we found that the use of robotics was associated with decreased intraoperative blood loss, fewer systemic complications, shorter hospitalizations, and eliminated readmissions. While long-term outcomes and patient selection criteria for robotic TAR repair are under investigations, we advocate selective use of robotics for TAR reconstructions in patients undergoing AWR.

Laparoscopic vs Robotic Intraperitoneal Mesh Repair for Incisional Hernia: An Americas Hernia Society Quality Collaborative Analysis

BACKGROUND

Robotic intraperitoneal mesh placement (rIPOM) has emerged recently as an alternative to laparoscopic intraperitoneal mesh placement (LapIPOM) for minimally invasive incisional hernia repair. We aimed to compare LapIPOM with rIPOM in terms of hospital length of stay (LOS) and 30-day postoperative complications in patients undergoing incisional hernia repair within the Americas Hernia Society Quality Collaborative.

STUDY DESIGN

Propensity score analysis was used to compare matched groups of patients within the Americas Hernia Society Quality Collaborative undergoing LapIPOM vs rIPOM. The primary outcomes measure was hospital LOS and secondary outcomes were 30-day wound events.

RESULTS

Four hundred and fifty-four (71.9%) patients underwent LapIPOM and 177 (28.1%) underwent rIPOM. The laparoscopic group had an increased median LOS (1 vs 0 days; interquartile range 3.00; p < 0.001). The risk of surgical site occurrence was higher in the LapIPOM group vs the rIPOM group (14% vs 5%; p = 0.001); however, surgical site occurrence requiring procedural intervention was similar between the groups (1% vs 0%; p = 1). Operative time longer than 2 hours was more common in the rIPOM group (47% vs 31%; p < 0.05).

CONCLUSIONS

Despite longer operative times using the rIPOM approach, patients undergoing rIPOM had a significantly shorter LOS than LapIPOM, without additional risk of wound morbidity requiring intervention. Additional studies are necessary to identify the best candidates for the rIPOM approach.