Learning curve of robot-assisted transabdominal preperitoneal (rTAPP) inguinal hernia repair: a cumulative sum (CUSUM) analysis

The Next Generation: Surgeon Learning Curve in a Mature Operative Rib Management Program

INTRODUCTION

Prior work has demonstrated utility in using operative time to measure surgeon learning for surgical stabilization of rib fractures (SSRF); however, no studies have used operative time to evaluate the benefit of proctoring in subsequent generations of surgeons. We sought to evaluate whether there is a difference in learning between an original series (TOS) of self-taught surgeons versus the next generation (TNG) of proctored surgeons using cumulative summation (CUSUM) analysis. We hypothesized that TNG would have a comparatively accelerated learning curve.

METHODS

A single-center retrospective review of all SSRF at a level 1 trauma center was performed. Data were collected from the beginning of an operative chest injury program to include at least 2 y of TNG experience. Operative time was used to determine success and misstep based on prior methods. Learning curves using CUSUM analysis were calculated based on an anticipated success rate of 90% and compared between TOS and TNG groups.

RESULTS

Over 7 y, 163 patients with a median Injury Severity Score of 24 underwent SSRF. Median operative time was 165 min with a 0.5 plate-to-fracture ratio. All three TOS surgeons experienced a positive slope indicative of early missteps for their first 15-20 cases. By contrast, all three TNG surgeons demonstrated a series of early successes resulting in negative CUSUM slopes which coincided with a period of proctoring. By the end of TNG series, the composite cumulative score was less than half of the TOS surgeon' scores.

CONCLUSIONS

Operative time continues to be a useful surrogate for observing SSRF learning curves. In a mature institutional program, proctored novice surgeons appear to have an accelerated learning curve compared to novice surgeons developing a new operative rib program.

Is implementation of robotic-assisted procedures in acute care general surgery cost-effective?

Over the past 2 decades, the use and importance of robotic surgery in minimally invasive surgery has increased. Across various surgical specialties, robotic technology has gained popularity through its use of 3D visualization, optimal ergonomic positioning, and precise instrument manipulation. This growing interest has also been seen in acute care surgery, where laparoscopic procedures are used more frequently. Despite the growing popularity of robotic surgery in the acute care surgical realm, there is very little research on the utility of robotics regarding its effects on health outcomes and cost-effectiveness. The current literature indicates some value in utilizing robotic technology in specific urgent procedures, such as cholecystectomies and incarcerated hernia repairs; however, the high cost of robotic surgery was found to be a potential barrier to its widespread use in acute care surgery. This narrative literature review aims to determine the cost-effectiveness of robotic-assisted surgery (RAS) in surgical procedures that are often done in urgent settings: cholecystectomies, inguinal hernia repair, ventral hernia repair, and appendectomies.

Safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in pioneering hospitals in Japan: A nationwide retrospective cohort study

INTRODUCTION

We aimed to evaluate the safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in 12 pioneering hospitals in Japan.

METHODS

Clinical data of patients who underwent robotic-assisted transabdominal preperitoneal repair between September 1, 2016, and December 31, 2021 were collected. Primary outcome measures were intra-operative adverse events and post-operative complications, whereas secondary outcomes were surgical outcomes, including chronic pain, recurrence, and learning curve.

RESULTS

In total, 307 patients were included. One case of inferior epigastric arterial injury was reported; no cases of bowel or bladder injury were reported. Thirty-five seromas were observed, including four (1.3%) cases that required aspiration. The median operative time of a unilateral case was 108 minutes (interquartile range: 89.8-125.5), and post-operative pain was rated 1 (interquartile range: 0-2) on the numerical rating scale. In complicated cases, such as recurrent inguinal hernias and robotic-assisted radical prostatectomy-associated hernias, dissection and suture were safely achieved, and no complications were observed, except for non-symptomatic seroma. All patients underwent robotic procedures, and there was no chronic post-operative inguinal pain, although one case of hernia recurrence was reported. Regarding the learning curve, plateau performance was achieved after 7-10 cases in terms of operative time (P < .001).

CONCLUSION

Robotic-assisted transabdominal preperitoneal repair can be safely introduced in Japan. Regardless of the involvement of many surgeons, the mastery of robotic techniques was achieved relatively quickly. The advantage of robotic technology such as wristed instruments may expand the application of minimally invasive hernia repair for complicated cases.

CUSUM learning curves: what they can and can't tell us

INTRODUCTION

There has been increased interest in assessing the surgeon learning curve for new skill acquisition. While there is no consensus around the best methodology, one of the most frequently used learning curve assessments in the surgical literature is the cumulative sum curve (CUSUM) of operative time. To demonstrate the limitations of this methodology, we assessed the CUSUM of console time across cohorts of surgeons with differing case acquisition rates while varying the total number of cases used to calculate the CUSUM.

METHODS

We compared the CUSUM curves of the average console times of surgeons who completed their first 20 robotic-assisted (RAS) cases in 13, 26, 39, and 52 weeks, respectively, for their first 50 and 100 cases, respectively. This analysis was performed for prostatectomy (1094 surgeons), malignant hysterectomy (737 surgeons), and inguinal hernia (1486 surgeons).

RESULTS

In all procedures, the CUSUM curve of the cohort of surgeons who completed their first 20 procedures in 13 weeks demonstrated a lower slope than cohorts of surgeons with slower case acquisition rates. The case number at which the peak of the CUSUM curve occurs uniformly increases when the total number of cases used in generation of the CUSUM chart changes from 50 to 100 cases.

CONCLUSION

The CUSUM analyses of these three procedures suggests that surgeons with fast initial case acquisition rates have less variability in their operative times over the course of their learning curve. The peak of the CUSUM curve, which is often used in surgical learning curve literature to denote "proficiency" is predictably influenced by the total number of procedures evaluated, suggesting that defining the peak as the point at which a surgeon has overcome the learning curve is subject to routine bias. The CUSUM peak, by itself, is an insufficient measure of "conquering the learning curve."

Differences in the learning curve of robotic transabdominal preperitoneal inguinal hernia repair according to surgeon's robotic experience

PURPOSE

In this study, we aim to analyze the learning curve of each step of robotic transabdominal pre-peritoneal inguinal hernia repair (rTAPP) in two surgeons with varying degrees of expertise with the robotic platform but no experience with laparoscopic hernia repair.

METHODS

Data on 124 rTAPP cases performed by two surgeons were retrospectively reviewed. Cumulative sum (CUSUM) analysis was applied to visualize the learning curve of rTAPP on operation time of each step of the procedure [the peritoneal flap creation (T1), the completion of the critical view of the myopectineal orifice (T2), the mesh application (T3) and the peritoneal flap closure (T4)]. Each intraoperative and postoperative outcome was compared according to surgeon's experience with the robotic platform and learning phase. The robotic surgeon mentored the surgeon-in-training and was present during all surgeries in his learning period.

RESULTS

The surgeon in training with the robotic platform showed a learning phase till the 20th procedure followed by a gradual improvement in performances. The expert surgeon showed a learning phase till the 35th procedure after which a constant decrease of operative time was recorded till the last procedure included. The operative times of each step of the procedures of both surgeons were significantly improved after the learning phase. In the late phase, the surgeon in training could achieve operative times in T2 and T3, which are similar to those of an experienced robotic surgeon with no experience with TAPP before the completion of the learning phase.

CONCLUSIONS

In conclusion, the learning phase of rTAPP surgery may vary between 20 and 35 cases, depending on the surgeon's experience in robotic surgery.

Impact of COVID-19 on clinical outcomes of robotic inguinal hernia repair

PURPOSE

To investigate the impact of the COVID-19 pandemic on the clinical impact of the clinical outcomes of robotic inguinal hernia repair.

METHODS

Patients who underwent RIHR 2 years before and after March 10, 2020, were included in this retrospective study and assigned accordingly to the pre- or post-COVID group. Pre-, intra-, and postoperative variables including patients' demographics, hernia characteristics, complications, and hernia recurrence rates were compared between groups.

RESULTS

183 (94.5% male) and 141 (96.4% male) patients were assigned to the pre- and post-COVID groups, respectively. Patient demographics and medical comorbidities did not differ between groups. Operative time was approximately 40 min longer in the post-COVID group (p < 0.001) with higher rates of bilateral IHR (pre-COVID: 30.1% vs. post-COVID: 46.4%, p = 0.003). Mesh material differed between groups with predominance of polyester mesh in the pre-COVID group vs. polypropylene in the post-COVID one. Median hospital length of stay (LOS) was 0 days in both groups, and same-day discharge rates were 93.4% pre-pandemic and 92.8% post-pandemic (p = 0.09). There were no pulmonary complications recorded in either group or no cases of COVID-19 detected within two weeks postoperatively in the post-COVID group. Seromas were more frequent in the post-COVID group (pre-COVID: 2 vs. post-COVID: 8, p = 0.018) and no hernia recurrences were recorded.

CONCLUSION

This is the first study to describe the impact of COVID-19 on RIHR. Clinical outcomes and hernia-specific complications were not impacted by the COVID-19 pandemic.

Comparison of short-term outcomes of robotic and laparoscopic transabdominal peritoneal repair for unilateral inguinal hernia: a propensity-score matched analysis

PURPOSE

This study aimed to compare perioperative outcomes of robotic and laparoscopic transabdominal peritoneal repair (TAPP) for unilateral inguinal hernia.

METHODS

This single institutional retrospective cohort study used de-identified data of patients who underwent robotic TAPP (R-TAPP) or laparoscopic TAPP (L-TAPP) for unilateral inguinal hernia between January 1, 2016 and October 31, 2021. Two cohorts were propensity matched, and data were analyzed. The learning curve was evaluated in the R-TAPP group.

RESULTS

Among 938 patients analyzed, 704 were included. After propensity-score matching, 80 patients were included in each group. The difference in operative time between R-TAPP and L-TAPP groups was 10 min (99.5 and 89.5 min, p = 0.087); however, console/laparoscopic time was similar (67 and 66 min, p = 0.71). The dissection time for medial-type hernia in the R-TAPP group was marginally shorter than that in the L-TAPP group (17 and 27 min, p = 0.056); however, there was no difference for lateral-type hernia (38.5 and 40 min p = 0.37). Perioperative variables, including estimated blood loss, postoperative hospital stay, and postoperative pain, had no significant difference, and chronic pain, which needed medication or intervention, was not observed in each group. The number of cases needed to achieve plateau performance was 7-10 in the R-TAPP group.

CONCLUSION

This study suggests that R-TAPP was safely introduced, and its perioperative outcomes were not inferior to those of L-TAPP. A shorter dissection time for medial-type hernia might be due to the robot's advantages, and a fast-learning curve could help with the early standardization of the procedure.

Early outcomes of robotic transabdominal preperitoneal inguinal hernia repair: a retrospective single-institution study in Korea

Purpose

Robotic hernia repair has increased in popularity since the introduction of da Vinci robots (Intuitive Surgical). However, we lack quantitative analyses of its potential benefits. Herein, we report our initial experience with robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair.

Methods

We retrospectively reviewed the data from patients who underwent R-TAPP inguinal hernia repair with a prosthetic mesh using the da Vinci platform. Data on patient characteristics and surgical outcomes were also collected.

Results

Twenty-one patients (including 20 male patients [95.2%]) with a mean age of 54.1 ±16.4 years and body mass index of 23.8 ± 1.9 kg/m2 underwent R-TAPP inguinal hernia repair. Bilateral hernia repair was performed in two patients (9.5%), and six patients (28.5%) with scrotal hernia underwent R-TAPP hernia repair. A sigmoid colon sliding hernia was present in three patients (14.3%). The mean operation and console times were 91.8 ± 20.4 minutes and 154.5 ± 26.2 minutes, and 61.4 ± 16.9 minutes and 128.0 ± 25.5 minutes for unilateral and bilateral inguinal hernia, respectively. Spermatic vessel injury was identified intraoperatively in one patient. Two minor postoperative complications, postoperative ileus, and wound seroma were reported. The mean duration of hospitalization was 3.8 ± 0.9 days. No recurrence or conversion to open surgery was required.

Conclusion

Our findings suggest that R-TAPP inguinal hernia repair is safe and feasible. Its cost-effectiveness, optimal procedural steps, and indications for a robotic approach require further investigation.

Towards identifying a learning curve for robotic abdominal wall reconstruction: a cumulative sum analysis

INTRODUCTION

Over the past decade, an increase has been seen in robotics used for hernia repair, specifically robotic abdominal wall reconstruction (rAWR). However, the learning curve for rAWR can be steep and presently, little is understood regarding the optimal case volume required to achieve proficiency. The aim of our study was to review skill acquisition and describe the learning curve for rAWR.

METHODS

A retrospective, single-surgeon case series of consecutive patients who underwent rAWR from 2018 to 2022. The primary outcome was operative time, obtained from console time identified through the MyIntutive application. A one-sided cumulative sum analysis (CUSUM) curve for the total operative time was derived based on the mean operative time of chronological procedures (207 min).

RESULTS

185 patients underwent rAWR between 2018 and 2022. These patients were more likely to be female, Caucasian, and have undergone two previous hernia repairs. ASA complexity increased over time with ASA 3 being predominant from 2020 onwards. The median hernia length was 15.0 cm and the median width was 7 cm. Average operative time was 207.8 min and decreased over time. The CUSUM analysis identified four phases of skill acquisition with the following case volumes: Initial Learning Curve (0-20), Stabilization Phase (21-55), Second Learning Curve (56-70), 4) Skill Proficiency (> 70).

CONCLUSION

In the early learning curve of rAWR, operative time decreased consistently after 70 cases, with an initial inflection after 20 cases. We identified varying stages of skill acquisition that are likely typical of a surgeon as they would progress through the learning curve of advanced robotic surgery. Future studies are needed to confirm the optimal case volume for determining the skill level for the performance of rAWR.

Initial Experience of Robot-Assisted Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair by a Single Surgeon in South Korea

Background and Objectives: Inguinal hernia is a common surgical disease. Traditional open herniorrhaphy has been replaced by laparoscopic herniorrhaphy. Nowadays, many attempts at robotic herniorrhaphy have been reported in western countries, but there have been no reports in South Korea. The purpose of this study is to report our initial experience with robotic inguinal hernia surgery, compared to laparoscopic inguinal hernia surgery. Materials and Methods: We analyzed the clinical data from 100 patients who received inguinal hernia surgery in our hospital from November 2020 to June 2022. Fifty patients underwent laparoscopic surgery, and 50 patients underwent robotic surgery using the da Vinci Xi system. All hernia surgeries were performed by a single surgeon using the transabdominal preperitoneal (TAPP) method. Results: The mean operation time and hospital stay were not statistically different. On the first postoperative day, the visual analog scale (VAS) pain score was significantly lower in the robotic surgery group (2.9 ± 0.5 versus 2.5 ± 0.7, p = 0.015). Cumulative sum analysis revealed an approximately 12-case learning curve for robotic-assisted TAPP hernia surgery. Conclusions: Robotic-assisted TAPP inguinal hernia surgery is technically acceptable to surgeons who have performed laparoscopic inguinal hernia surgery, and the learning curve is relatively short. It is thought to be a good step toward learning other robot-assisted operations.

Short-term outcomes of robotic inguinal hernia repair during robotic prostatectomy - An analysis of the Abdominal Core Health Quality Collaborative

BACKGROUND

Concomitant robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR) has been reported. Nevertheless, data on its safety is lacking and some surgeons avoid performing both operations concurrently due to the potential risk of mesh related complications in the setting of a fresh vesicourethral anastomosis. We aimed to investigate differences in 30-day outcomes between patients undergoing RALP+RIHR and those undergoing RIHR alone.

METHODS

Patients who have undergone concomitant RALP and RIHR with 30-day follow-up available were identified within the Abdominal Core Health Quality Collaborative. Using a propensity score algorithm, they were matched with a cohort of patients undergoing RIHR alone based on confounders such as body mass index, age, ASA class, smoking, hernia size and recurrent status and prior pelvic operation. The groups were compared for 30-day rates of surgical site infection (SSI), surgical site occurrences (SSO), surgical site occurrences requiring operative intervention (SSOPI) and hernia recurrence.

RESULTS

24 patients underwent RALP + RIHR and were matched to 72 patients who underwent RIHR alone (3:1). Median age was 64 years, 33% were obese and 17% smokers. No significant differences were found on 30-day rates of overall complications (21% RALP + RIHR vs. 15% RIHR, p = 0.53) and surgical site occurrences (12% RALP + RIHR vs.11% RIHR, p = 0.85). No patient in the RALP + RIHR group had a 30-day SSI, SSOPI or early recurrence.

CONCLUSION

RALP+RIHR appears not to result in increased rates of wound complications, overall complications or early recurrence when compared to patient undergoing RIHR alone. Prospective, controlled studies with larger number of patients are needed to confirm our findings.

Comparison of perioperative and mid-term outcomes between laparoscopic and robotic inguinal hernia repair

BACKGROUND

Although the advantages of laparoscopic inguinal hernia repair (LIHR) have been described, guidelines regarding robotic inguinal hernia repair (RIHR) have yet to be established, despite its increased adoption as a minimally invasive alternative. This study compares the largest single-center cohorts of LIHR and RIHR and aims to shed light on the differences in outcomes between these two techniques.

METHODS

Patients who underwent LIHR or RIHR over an 8-year period were included as part of a retrospective analysis. Variables were stratified by preoperative, intraoperative, and postoperative timeframes. Complications were listed according to the Clavien-Dindo classification system and comprehensive complication index (CCI®). Study groups were compared using univariate analyses and Kaplan-Meier's time-to-event analysis.

RESULTS

A total of 1153 patients were included: 606 patients underwent LIHR, while 547 underwent RIHR. Although demographics and comorbidities were mostly similar between the groups, the RIHR group included a higher proportion of complex hernias. Operative times were in favor of LIHR (42 vs. 53 min, p < 0.001), while RIHR had a smaller number of peritoneal breaches (0.4 vs. 3.8%, p < 0.001) as well as conversions (0.2 vs. 2.8%, p < 0.001). The number of patients lost-to-follow-up and the average follow-up times were similar (p = 0.821 and p = 0.304, respectively). Postoperatively, CCI® scores did not differ between the two groups (median = 0, p = 0.380), but Grade IIIB complications (1.2 vs. 3.3%, p = 0.025) and recurrences (0.8% vs. 2.9%, p = 0.013) were in favor of RIHR. Furthermore, estimated recurrence-free time was higher in the RIHR group [p = 0.032; 99.7 months (95% CI 98.8-100.5) vs. 97.6 months (95% CI 95.9-99.3).

CONCLUSION

This study demonstrated that RIHR may confer advantages over LIHR in terms of addressing more complex repairs while simultaneously reducing conversion and recurrence rates, at the expense of prolonged operation times. Further large-scale prospective studies and trials are needed to validate these findings and better understand whether RIHR offers substantial clinical benefit compared with LIHR.

Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper

BACKGROUND

Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS.

METHODS

This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements.

RESULTS

Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency.

CONCLUSIONS

Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research.

A method for identifying the learning curve for the surgical stabilization of rib fractures

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is an accepted efficacious treatment modality for patients with severe chest wall injuries. Despite increased adoption of SSRF, surgical learning curves are unknown. We hypothesized intraoperative duration could define individual SSRF learning curves.

METHODS

Consecutive SSRF operations between January 2017 and December 2021 at a single institution were reviewed. Operative time, as measured from incision until skin closure, was evaluated by cumulative sum methodology using a range of acceptable "missteps" to determine the learning curves. Misstep was defined by extrapolation of accumulated operative time data.

RESULTS

Eighty-three patients underwent SSRF by three surgeons during this retrospective review. Average operative times ranged from 135 minutes for two plates to 247 minutes for seven plates. Using polynomial regression of average operative times, 75 minutes for general procedural requirements plus 35 minutes per plate were derived as the anticipated operative times per procedure. Cumulative sum analyses using 5%, 10%, 15%, and 20% incident rates for not meeting expected operative times, or "missteps" were used. An institutional learning curve between 15 and 55 SSRF operations was identified assuming a 90% performance rate. An individual learning curve of 15 to 20 operations assuming a 90% performance rate was observed. After this period, operative times stabilized or decreased for surgeons A, B, and C.

CONCLUSION

The institutional and individual surgeon learning curves for SSRF appears to steadily improve after 15 to 20 operations using operative time as a surrogate for performance. The implementation of SSRF programs by trauma/acute care surgeons is feasible with an attainable learning curve.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Description of the Current Da Vinci® Training Pathway for Robotic Abdominal Wall Surgery by the European Hernia Society

Background: Robot assisted laparoscopic abdominal wall surgery (RAWS) has seen a rapid adoption in recent years. The safe introduction of the robot platform in the treatment of abdominal wall hernias is important to safeguard the patient from harm during the learning curve. The scope of this paper is to describe the current European training curriculum in RAWS. Methods and Analysis: The pathway to competence in RAWS will depend on the robot platform, experience in other abdominal procedures (novice to expert) and experience in the abdominal wall repair techniques. An overview of the learning curve effect in the initial case series of several early adopters in RAWS was reviewed. In European centres, current training for surgeons wanting to adopt RAWS is managed by the specific technology-based training organized by the company providing the robot. It consists of four phases where phases I and II are preclinical, while phases III and IV focus on the introduction of the robotic platform into surgical practice. Conclusion: On behalf of the Robotic Surgery Task Force of the European Hernia Society (EHS) we believe that the EHS should play an important role in the clinical phases III and IV training. Courses organized in collaboration with the robot provider on relevant surgical anatomy of the abdominal wall and procedural steps in complex abdominal wall reconstruction like transversus abdominis release are essential. Whereas the robot provider should be responsible for the preclinical phases I and II to gain familiarity in the specific robot platform.

Robotic hernia repair II. English version : Robotic primary ventral and incisional hernia repair (rv‑TAPP and r‑Rives or r‑TARUP). Video report and results of a series of 118 patients

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r‑ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r‑TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

[Robotic hernia repair : Part II: Robotic primary ventral and incisional hernia repair (rv-TAPP and r-Rives or r-TARUP). Video report and results of a series of 118 patients]

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r‑ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r‑TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

Comparison of perioperative outcomes between non-obese and obese patients undergoing robotic inguinal hernia repair: a propensity score matching analysis

PURPOSE

Despite the limited research in support of robotic inguinal hernia repair (RIHR), it is an increasingly adopted technique in surgical practice. While a major risk factor for the development of ventral hernias and subsequent complications, obesity in RIHR has not been investigated. The aim of this study was to compare the outcomes of RIHR between obese and non-obese patients.

METHODS

Prospectively collected data surrounding RIHRs performed at a single center between 2013 and 2020 were retrospectively reviewed. Patients were divided into non-obese (< 30 kg/m²) and obese (≥ 30 kg/m²) groups, and preoperative, intraoperative, and postoperative variables were compared in unmatched and matched groups, derived using a 1:2 propensity score match (PSM).

RESULTS

From a total of 547 patients, 414 were non-obese and 133 were obese. A PSM analysis, accounting for confounding preoperative variables and risk factors, stratified these into 262 patients for the non-obese group and 131 patients for the obese group. Although the obese group's operative times were longer on average (57 min vs. 51 min; p = 0.007), this difference did not persist after matching. The only significant difference in operative variables was a higher rate of cord lipomas in the obese group. Postoperative variables, including wound complications, readmissions, and recurrence, were similar across unmatched and matched groups.

CONCLUSION

In the first study to investigate the influence of obesity in RIHR, no differences in outcomes were found between obese and non-obese patients. This procedure can be safely performed in obese individuals, however, more studies comparing body mass index (BMI) classes are needed to establish whether a prohibitive BMI threshold exists for RIHR.