SubCutaneous OnLay endoscopic Approach (SCOLA) mesh repair for small midline ventral hernias with diastasis recti: An initial US experience

Robotic-assisted endoscopic onlay repair (R-ENDOR) for concomitant ventral hernias and diastasis recti: initial results and surgical technique

BACKGROUND

The surgical management of midline ventral hernias complicated by concomitant diastasis recti presents a significant clinical challenge. The Endoscopic Onlay Repair (ENDOR) offers a minimally invasive solution, effectively addressing both conditions. This study focuses on describing the adaptation of ENDOR to a robotic platform, termed R-ENDOR, aiming to report initial outcomes along with other established robotic surgical approaches.

METHODS

This retrospective case series study included consecutive adult patients who underwent R-ENDOR approach from October 2018 to April 2023, performed by a single surgeon. A comprehensive description of the surgical technique is included. Patient demographics, operative, and hernia-specific characteristics, as well as clinical outcomes are described.

RESULTS

A total of 15 patients undergoing R-ENDOR for ventral hernia repair with diastasis recti plication were included. The median age was 59 years (IQR 42-63), with 60% (n = 9) female patients. The majority (86%, n = 13) had an ASA score of ≤ 2, and the median BMI was 24 kg/m2, with 20% (n = 3) classified as obese. Median hernia size was 2 cm (IQR 2-2.25), with a median diastasis length of 19 cm (IQR 15-21.5) and width of 4 cm (IQR 3-6). The median operative time was 129 min (IQR 113-166). Most repairs (93%, n = 14) were reinforced with mesh, predominantly self-fixating (73.3%, n = 11). Eighty percent of patients (n = 12) were discharged on the same day, with a median follow-up of 153 days (IQR 55-309). Notable complications included clinically significant seromas in 20% of patients (n = 3), long-term hypoesthesia in 40% (n = 6), and readmission in one patient (6.6%) for surgical site infection (SSI) requiring IV antibiotic therapy.

CONCLUSION

Midline ventral hernias associated to diastasis recti can be managed robotically by ENDOR with safe and consistent 90-day outcomes in a carefully selected group of patients.

Endoscopic-assisted repair of combined ventral hernias and diastasis recti: minimizing seroma incidence by quilting

BACKGROUND

To reduce the incidence of seromas, we have adapted the quilting procedure used in open abdominoplasty to the endoscopic-assisted repair of concomitant ventral hernia (VH) and diastasis recti (DR). The aim of this study was to describe the technique and assess its efficacy by comparing two groups of patients operated on with the same repair technique before and after introducing the quilting.

METHODS

This retrospective study included data prospectively registered in the French Club Hernie database from 176 consecutive patients who underwent surgery for concomitant VH and DR via the double-layer suturing technique. Patients were categorized into two groups: Group 1 comprised 102 patients operated before introducing the quilting procedure and Group 2 comprised 74 operated after introducing the quilting. To carry out comparisons between groups, seromas were classified into two types: type A included spontaneously resorbable seromas and seromas drained by a single puncture and type B included seromas requiring two or more punctures and complicated cases requiring reoperation.

RESULTS

The global percentage of seromas was 24.4%. The percentage of seromas of any type was greater in Group 1 (27.5%) than in Group 2 (20.3%). The percentage of Type B seromas was greater in Group 1 (19.6%) than in Group 2 (5.4%), when the percentage of Type A seromas was greater in Group 2 (14.9) than in Group 1 (7.9%). Differences were significant (p = 0.014). The operation duration was longer in Group 2 (83.9 min) than in Group 1 (69.9 min). Four complications requiring reoperation were observed in Group 1: three persistent seromas requiring surgical drainage under general anesthesia and one encapsulated seroma.

CONCLUSION

Adapting the quilting technique to the endoscopic-assisted bilayer suturing technique for combined VH and DR repair can significantly reduce the incidence and severity of postoperative seromas.

Endoscopic treatment of diastasis recti: Training method and literature review

INTRODUCTION

Endoscopic treatment of diastasis rectus abdominis offers the possibility of correcting the condition without complete abdominoplasty. The purpose of this study was to develop a training method on fresh cadavers models based on a literature review on this surgery.

MATERIAL AND METHODS

The endoscopic procedure considered involved the insertion of a 10mm suprapubic trocar and of 5mm trocars in each iliac fossae. The muscle suture is done using running barbed suture. The surgery was performed on eight fresh cadavers to estimate the learning curve for this intervention, which was estimated with the CUSUM method. A systematic literature review in the PubMed database was performed, and 20 articles that met the inclusion criteria were analyzed.

RESULTS

The learning curve threshold was reached after 6 operations and can be separated into two phases. The most common complication of this surgery is seroma, it is encountered in 3 to 27% of cases according to the studies. Diastasis recurrence is rare, occurring in less than 2% of cases. In comparison, open surgical treatment of diastasis recti is associated with a higher risk of hematoma, skin necrosis and longer operating times. Recurrence rates are similarly low after open and endoscopic repair. Mesh reinforcement is indicated in cases of diastasis wider than 5cm, diastasis recurrence, severe musculoaponeurotic laxity, or hernia larger than 1cm.

CONCLUSION

The data in the literature indicate that laparoscopic surgery is an efficient and safe approach to correct diastasis of the rectus muscles and can be offered by plastic surgeons to selected patients.

An Algorithmic Approach for the MIS Repair of Ventral Midline Hernias Associated With Diastasis of the Rectus Abdominis Muscle

Purpose: We present our algorithmic approach for symptomatic ventral hernias with Diastasis of the Rectus Abdominis Muscle (DRAM). Methods: Retrospective analysis of patients with symptomatic ventral hernias and DRAM undergoing hernia repair and plication of DRAM from July 2018-March 2021 was conducted. Based on our algorithm, patients were selected for an Endoscopic Onlay Repair (ENDOR) or a Robotic Extended Totally Extraperitoneal Ventral Repair (R-eTEP). Results: We performed a R-eTEP in fifty-seven patients and an ENDOR in twenty-four patients. In the R-eTEP group, thirty-seven (65%) patients were female, the mean age was 54.8 (±10.6), and the mean BMI was 32 (±4.8). Fifty patients (87.7%) had multiple defects, of which 19 (38%) were recurrent hernias and 31 (62%) were incisional hernias. The mean operative time was 200 (±62.4) minutes, with two cases requiring a hybrid approach. The median length of stay was 1 day (0-12), and the median follow-up was 103 days. Twenty-four patients underwent an ENDOR, 19 females (79.2%), the mean age was 45.7 years (±11.7) and the mean BMI was 28 (±3.6). 13 patients had isolated umbilical or epigastric hernias. The mean operative time was 146.2 min (±51.1). Fibrin sealant and suture was the predominant method for mesh fixation, and most cases were performed in an ambulatory setting. Four patients developed post-operative seromas; one requiring drainage due to infection. The Median follow-up was 48.5 days (10-523), with two reported hernia recurrences. Conclusion: An algorithmic approach for adequate patient selection was shown to be safe for treating ventral hernias with DRAM.

A Novel Modification of Subcutaneous Onlay Endoscopic Repair of Midline Ventral Hernias With Diastasis Recti: An Indian Experience

Introduction

A ventral hernia is a common problem in the population. Many patients with umbilical/epigastric hernia often present with diastasis recti (DR) too. Diastasis recti is the thinning of the linea alba with an abnormal increase in the distance between the recti without a concomitant fascial defect. The presence of diastasis recti complicates the repair of the existing umbilical/epigastric hernia. Repair of only the umbilical/epigastric hernia in the presence of DR results in incomplete repair and predisposes to recurrence. There are various options available for the repair of umbilical hernia with diastasis recti. Open hernia repairs often have unsatisfactory cosmetic outcomes and, furthermore, involve complications frequently associated with large incisions such as surgical site occurrences (SSO), pain, dermal flap necrosis, and delayed postoperative recovery, to name a few. The era of minimal access surgery leaves us with a vast array of creative solutions to the same. Laparoscopic onlay repair has been given various names in literature, e.g., minimally invasive linea alba reconstruction (MILAR), pre-aponeurotic endoscopic repair (REPA), endoscopic linea alba reconstruction (ELAR), subcutaneous onlay laparoscopic approach (SCOLA), and totally endoscopic assisted linea alba reconstruction (TESLAR), with similar principles for all the procedures. The average rate of seroma formation in these procedures varies from 5% to 40%. SCOLA has been used in our study, with an added modification of the operating port and limiting the extent of lateral dissection with the aid of spinal needles, resulting in restrained dissection and creation of smaller lipocutaneous flaps, leading to reduced incidence of seroma formation.

Methods

Patients with symptomatic primary ventral hernia with concomitant diastasis recti were enrolled in the participating center from the period of May 2020 to December 2021. Thirty patients were enrolled for this prospective study. The patients underwent subcutaneous laparoscopic onlay repair of midline ventral hernia with diastasis recti, with plication of the defect and onlay placement of a polypropylene mesh.

Results

Six point sixty-six percent (6.66%) of the patients developed seroma and SSO. The incidence is congruent with the results available in current literature. None of the patients had necrosis of umbilical skin. There were no recurrences at the three months follow-up.

Conclusion

Our modification of SCOLA is an ergonomically favorable procedure and has comparable outcomes to other approaches, with minimal complications.

Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review

BACKGROUND

A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different countries. The aim of this systematic review is to assess the safety and feasibility of different named techniques with the same surgical concept.

METHODS

The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score system was used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study designs, risk of bias, publication bias, heterogeneity, and statistical analysis.

RESULTS

The systematic literature search found 2548 articles, 317 of which were duplicates and excluded from analysis. The titles and abstracts from the remaining 2231 articles were assessed. After careful evaluation, 2125 articles were determined to be unrelated to our study and subsequently excluded. The full text of the remaining 106 articles was thoroughly assessed. Case reports, editorials, letters to the editor, and general reviews were then excluded. A total of 13 articles were ultimately included for this review, describing a similar subcutaneous endoscopic approach for repair of concomitant ventral hernias and rectus diastasis defined under nine different named techniques on 716 patients. The number of patients in those studies varied from 10 to 201. The mean operative time varied from 68.5 to 195 min. The most common complication was seroma, followed by pain requiring intervention, hematoma, and surgical site infection.

CONCLUSIONS

There are a few technique variations described in different studies, but with no significant differences in outcomes. We, therefore, propose to unify these procedures under one term, ENDoscopic Onlay Repair (ENDOR). This technique has shown to be effective and safe, with seroma being the most common complication.

Closing the gap: evidence-based surgical treatment of rectus diastasis associated with abdominal wall hernias

PURPOSE

Rectus diastasis (RD) associated with abdominal hernias present a surgical challenge associated with a paucity in treatment guidelines. The objective of this systematic review is to review surgical techniques and assess complication and recurrence rates of RD in patients with concurrent abdominal hernias.

METHODS

PubMed and EMBASE databases were systematically searched, and data extraction was performed on articles which met the inclusion criteria. Pooled analyses of complication and recurrence rates were performed to compare open vs. minimally invasive surgery. Student t tests were performed to compare differences in continuous outcomes.

RESULTS

Twenty-eight studies were included in this review. RD can be surgically repaired by both open and laparoscopic approaches using both non-absorbable and absorbable sutures. The majority of the techniques reported included mesh insertion either above the aponeurosis, retromuscular, preperitoneal, or intraperitoneal. Open techniques, compared to laparoscopic approaches, were associated with a significantly higher rate of skin dehiscence (6.79% vs. 2.86%; p = 0.003) and hematoma formation (4.73% vs. 1.09%; p < 0.001) and a significantly lower rate of post-operative seroma formation (2.47% vs. 8.29%; p < 0.001). No significant difference in RD recurrence rates were observed between open and laparoscopic repair (0.22 vs. 0.63%, p = 0.17).

CONCLUSION

Both open and laparoscopic surgery are safe and effective methods that can be used to repair RD in patients with RD and concurrent abdominal hernias as evident by the low recurrence and complication rates and almost negligible major complications post repair.

SubCutaneous OnLay endoscopic Approach (SCOLA) for midline ventral hernias associated with diastasis recti

INTRODUCTION

Minimally invasive surgery for diastasis recti has gained attention in the recent past, with several reports with different names and particularities being suggested by the authors. SCOLA (Subcutaneous OnLay endoscopic Approach) is an example of this technique, described here in standardized technique.

DESCRIPTION OF THE TECHNIQUE

Basic steps to perform the procedure are detailed, beginning with patient and surgical team positioning, including trocar placement and tips and tricks of the subcutaneous dissection, steps needed to achieve full dissection of the preaponeurotic space, diastasis recti plication, mesh positioning and fixation and drain positioning with fixation of the umbilical stalk.

DISCUSSION

Regardless of different names and small technical variations, endoscopic pre-aponeurotic mesh positioning can be performed with well-established steps on a reproducible fashion, aiming to achieve better results. Careful attention should be paid to appropriate patient selection and drain placement to reduce seroma rate, the most common complication.

Preaponeurotic endoscopic repair (REPA) of diastasis recti: a single surgeon's experience

BACKGROUND

Diastasis recti is a pathology that affects not only the abdominal wall but also the stability of lumbopelvic muscles, consequently altering urinary and digestive functionality. Preaponeurotic endoscopic repair (REPA) is an endoscopic alternative to tummy tuck for the treatment of diastasis. In this study, the outcomes of REPA application by a single surgeon are presented.

METHODS

A total of 172 patients underwent REPA for the treatment of diastasis recti between August 2017 and December 2019. One hundred twenty-four patients were followed for at least one year. Sixty-three patients responded to a survey on satisfaction and quality of life 12 months after surgery.

RESULTS

Three (2.4%) recurrences occurred, of which two occurred in the same patient. The main postoperative complications observed were 12 (9.7%) seromas, 3 (2.4%) haematomas, a single wound infection, 3 (2.4%) cases of skin fold formation, and a case of trophic skin lesion that required negative pressure therapy. Quality of life after surgery, as reported by 63 patients who responded to the survey, was satisfactory.

CONCLUSIONS

REPA is a safe and effective technique for diastasis recti treatment, representing a valid alternative to abdominoplasty. Since there is no need to access the peritoneal cavity and the mesh is onlay, there are no risks of bowel damage or adhesions between the intestine and prosthesis.