Hybrid versus open retromuscular abdominal wall repair: early outcomes

Short-term outcomes of minimally invasive techniques in posterior component separation for ventral hernia repair: a systematic review and meta-analysis

INTRODUCTION

The objective of this study was to perform a systematic review and meta-analysis to summarize various approaches in performing minimally invasive posterior component separation (MIS PCS) and ascertain their safety and short-term outcomes.

METHODS

A systematic literature searches of major databases were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify studies that provided perioperative characteristics and postoperative outcomes of MIS PCS. Primary outcomes for this study were: surgical site events (SSE), surgical site occurrence requiring procedural intervention (SSOPI), and overall complication rates. A random-effect meta-analysis was conducted which allows computation of 95% CIs using simple approximation and incorporates inverse variance method with logit transformation of proportions.

RESULTS

There were 14 studies that enrolled 850 participants that were included. The study identified rate of SSE, SSOPI, and overall rate of complications of all MIS TAR modifications to be 13.4%, 5.7%, and 19%, respectively.

CONCLUSIONS

Our study provides important information on safety and short-term outcomes of MIS PCS. These data can be used as reference when counseling patients, calculating sample size for prospective trials, setting up targets for prospective audit of hernia centers. Standardization of reporting of preoperative characteristics and postoperative outcomes of patients undergoing MIS PCS and strict audit of the procedure through introduction of prospective national and international registries can facilitate improvement of safety of the MIS complex abdominal wall reconstruction, and help in identifying the safest and most cost-effective modification.

A comparison of robotic enhanced-view totally extraperitoneal approach versus trans-abdominal retro-muscular approach for midline ventral hernias

BACKGROUND

The evolution of midline ventral hernia repair has progressed from the open Rives-Stoppa technique to minimally invasive robotic approaches, notably the trans-abdominal retromuscular (TARM) and enhanced-view Totally Extraperitoneal (eTEP) methods. This study compares these two robotic techniques in repairing medium-sized midline ventral hernias.

METHODS

A retrospective comparative study of electronic medical records from 2015 to 2021 was conducted on patients undergoing robotic TARM or eTEP at NYU Langone Hospital-Long Island. Data on demographics, comorbid conditions, surgical history, intraoperative details, hernia characteristics, and postoperative outcomes were analyzed.

RESULTS

Both eTEP and TARM groups exhibited comparable outcomes regarding operative duration, hernia defect size, and overall complications. However, notable differences were observed in patients' BMI, implanted mesh area, mesh composition, and fixation techniques across the groups. The TARM group required a longer hospital stay (median: 1 day) in contrast to the eTEP group (median: 0 days). Additionally, eTEP patients indicated reduced postoperative pain scores (median: 2) compared to TARM (median: 3), with both differences being statistically significant (p < 0.001).

CONCLUSION

The robotic eTEP approach is associated with lower post-operative pain scores, decreased hospital length of stay, and larger areas of mesh implantation as compared to the TARM approach. Other variables are largely comparable between the two techniques.

LEVEL OF EVIDENCE

Level III.

Mini- or less-open sublay (E/MILOS) operation vs open sublay and laparoscopic IPOM repair for the treatment of incisional hernias: a registry-based propensity score matched analysis of the 5-year results

BACKGROUND

Open sublay and laparoscopic IPOM repair have specific disadvantages and risks. In recent years, this evidence led to a paradigm shift and induced the development of new minimally invasive techniques of sublay mesh repair.

METHODS

Pioneering this trend, we developed the endoscopically assisted mini- or less-open sublay (MILOS) concept. The operation is performed trans-hernially via a small incision with light-holding laparoscopic instruments either under direct, or endoscopic visualization. After dissection of an extra-peritoneal space of at least 8 cm, port placement and CO2 insufflation, each MILOS operation can be continued endoscopically (EMILOS repair). All E/MILOS operations were prospectively documented in the Herniamed Registry with 1- and 5-year questionnaire follow-ups. Propensity score matching of incisional hernia operations comparing the results of the E/MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from all other institutions participating in the Herniamed Registry was performed. The results with perioperative complications and 1-year follow-up have been published previously.

RESULTS

This paper reports on the 5-year results. The 5-year follow-up rate was 87.5% (538 of 615 patients with E/MILOS incisional hernia operations). Comparing E/MILOS repair with laparoscopic IPOM and open sublay operation, propensity score matching analysis was possible with 448 and 520 pairs of operations, respectively. Compared with laparoscopic IPOM incisional hernia operation, the E/MILOS repair is associated with significantly fewer general complications (P = 0.004), recurrences (P < 0.001), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.016) and tends to result in fewer postoperative complications (P = 0.052), and less pain at rest (P = 0.053). Matched pair analysis with open sublay repair revealed significantly fewer general complications (P < 0.001), postoperative complications (P < 0.001), recurrences (P = 0.002), less pain at rest (P = 0.004), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.014). A limitation of this analysis is a relative low 5-year follow-up rate for laparoscopic IPOM and open sublay.

CONCLUSIONS

The E/MILOS technique allows minimally invasive trans-hernial repair of incisional hernias using large standard meshes with low morbidity and good long-term results. The technique combines the advantages of sub-lay repair and a mini- or less-invasive approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03133000.

Analysis of 'enhanced-view totally extra-peritoneal' (eTEP) approach for ventral hernia: Early results

Introduction

Laparoscopic ventral hernia repair is undergoing a paradigm shift with the introduction of numerous new techniques to improve the outcomes. Enhanced-view totally extra-peritoneal (eTEP) is a novel approach for the repair of ventral herniae introduced by Belyansky et al. The key innovation lies in placing the mesh in a large retrorectus-pre-peritoneal space contrary to the widely practiced intra-peritoneal placement. This approach can be easily coupled with a component separation in the form of transversus abdominis release (TAR) for large herniae. We conducted a midterm analysis of 'eTEP' approach to ventral hernia at a high-volume tertiary care centre and present our results of over 3 years of employing this technique.

Methodology

A retrospective study of 150 cases of ventral hernia repaired using eTEP approach from January 2018 to February 2021 at a tertiary care centre by a team of three surgeons. The procedures were performed by a single team of three members headed by the first author.

Results

Out of total 150 cases, incisional hernia occurred in 73 cases (48.7%), primary hernia occurred in 48 cases (32%) and recurrent hernia in 29 cases (19.3%). Although the majority of incisional (87.7%) and recurrent (79.3%) ventral hernias occurred in female, the incidence of primary ventral hernia was equal at 24 cases in both genders. The majority of the cases (80.7%) underwent eTEP RS procedure, and the rest were W3 hernias, which were managed by including a component separation in the form of eTEP TAR. The operating time for eTEP TAR (222.24 min ± 32.56) compared to eTEP RS (124.33 ± 23.68) was significantly longer. The mean length of stay was significantly shorter for primary hernias (3.75 days ± 1.62) compared to recurrent (5.21 days ± 2.51) and incisional hernias (4.36 days ± 2.19) (F = 4.376) (P = 0.014). The peri-operative period was uneventful in majority of the cases. We experienced a seroma rate of 5.8% in our series. At follow-up of 1 year, 3.3% of patients complained of discomfort/bulge in the upper abdomen. There were no other surgical site occurrences (SSO) in the form infection, posterior rectus sheath disruption and skin necrosis. We observed no recurrences till date with a minimum follow-up of 1 year.

Conclusion

eTEP approach to ventral hernia is a promising abdominal wall reconstruction technique. It is safe and offers good functional outcomes with restoration of abdominal wall dynamics. It is a reproducible and safe technique for tackling various types of ventral hernia. It is specifically useful in managing unusual lateral hernias, incisional and recurrent hernias with ease.

Hybrid operation technique for incisional hernia repair: a systematic review and meta-analysis of intra- and postoperative complications

Background

Incisional hernia (IH) occurs approximately in 15% of patients after midline surgery. Surgical treatment for IHs include a solely open or solely laparoscopic approach with mesh placement. Recently, hybrid (combined laparoscopic and open) approaches have been introduced. This systematic review evaluates perioperative complications of hybrid incisional hernia repair (HIHR).

Methods

EMBASE, Medline via OvidSP, Web of Science, Cochrane and Google Scholar databases were searched. Studies providing data on intra- and postoperative complications in patients who underwent HIHR were included. Data on intra- and postoperative complications were extracted and meta-analyses were performed. Study quality was assessed with the Newcastle Ottowa Scale, ROBINS-I tool, and Cochrane risk of bias. PROSPERO registration: CRD42020175053.

Results

Eleven studies (n = 1681 patients) were included. Five studies compared intra-operative complications between HIHR and laparoscopic incisional hernia repair (LIHR) with a pooled incidence of 1.8% in HIHR group and 2.8% in LIHR group (p = 0.13). Comparison of postoperative prevalence of surgical site occurrences (SSOs) (23% versus 26%, p = 0.02) and surgical site occurrences requiring interventions (SSOPIs) (1.5% versus 4.1%, p < 0.01) were in favour of the HIHR group. Overall postoperative complications seemed to occur less frequent in the HIHR group, though no hard statements could be made due to the vast heterogeneity in reporting between studies.

Conclusion

Although the majority of studies were retrospective and included a small number of patients, HIHR seemingly led to less SSOs and SSOPIs. This systematic review forms a strong invitation for more randomized controlled trials to confirm the benefits of this approach.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02497-3.