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

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.

Clinical outcomes and costs of retromuscular and intraperitoneal onlay mesh techniques in robotic incisional hernia repair

BACKGROUND

This study aims to compare clinical outcomes and financial cost of intraperitoneal onlay mesh (IPOM) versus retromuscular (RM) repairs in robotic incisional hernia repairs (rIHR).

METHODS

Patients who underwent either IPOM or RM elective rIHR from 2012 to 2022 were included. Demographics, operative details, postoperative outcomes, and hospital costs were directly compared.

RESULTS

Sixty-nine IPOM and 55 RM were included. Age and body mass index (BMI) did not differ between both groups (IPOM vs RM: 59.3 ± 11.2 years vs. 57.5 ± 14 years, p = 0.423; BMI 34.1 ± 6.3 vs. BMI 33.2 ± 6.9, p = 0.435, respectively). Comorbidities and hernia characteristics were comparable. Extensive lysis of adhesions (> 30 min) was required more often in IPOM (18 vs. 6 in RM, p = 0.034). Defect closure was achieved in 100% of RM vs. 81.2% in IPOM (p < 0.001). Median (interquartile range) postoperative pain score was higher in RM than in IPOM [5(3-7) vs. 4(3-5), respectively, p = 0.006]. Median length of stay (0 day) and same-day discharge rate did not differ between groups (p = 0.598, p = 0.669, respectively). Six (8.7%) patients in the IPOM group versus one (1.8%) patient in the RM group were readmitted to hospital within 30 days postoperatively (p = 0.099). Perioperative complications were higher in IPOM (p = 0.011; 34.8% vs. 14.5% in RM) with higher Comprehensive Complication Index® morbidity scores [0(0-12.2) vs 0(0-0) in RM, p = 0.008)], Clavien-Dindo grade-II complications (8 vs 0 in RM, p = 0.009), and surgical site events (17 vs. 5 in RM, p = 0.024). Within a follow-up period of 57(± 28) months, recurrence rates were similar between both groups. Hospital costs did not differ between groups [IPOM: $9978 (7031-12,926) vs. RM: $8961(6701-11,222), p = 0.300]. Although postoperative complication costs were higher in IPOM ($2436 vs RM: $161, p = 0.020), total costs were comparable [IPOM: $12,415(8700-16,130) vs. RM: $9123(6789-11,457), p = 0.080].

CONCLUSION

Despite retromuscular repairs having lower postoperative complications than intraperitoneal onlay mesh repairs, both techniques offered encouraging results in robotic incisional hernia repair at a comparable total cost.

Robotic thoracoabdominal hernia repair: a novel approach

PURPOSE

Thoracoabdominal hernias remain a rare and poorly understood entity. Data remain sparse as terminology varies in the literature and case reports demonstrate wide variability in technique. We present a novel approach for repair of thoracoabdominal hernias using the robotic platform.

METHODS

Two patients underwent a robotic thoracoabdominal hernia repair in June 2022. They were followed for 1 year with CT scans every 6 months to exclude recurrence. Patient demographics and peri-operative details including defect size, closure technique, mesh size, length of stay, and complications were reported.

RESULTS

Both patients successfully underwent a robotic repair of a thoracoabdominal hernia, addressing the intercostal hernia, diaphragmatic disruption, and flank hernia discretely during the operation. One patient had an uneventful recovery and discharged on post-operative day 3; the other developed a small bowel obstruction due to an early port site hernia which required surgical intervention. He eventually discharged on post-operative day 9. At one year, there is no clinical or radiographic evidence of recurrence for either patient.

CONCLUSION

Robotic thoracoabdominal hernia repair is feasible and offers a minimally invasive repair option for these extremely complex hernias.

Robotic-assisted repair of incisional hernia-early experiences of a university robotic hernia program and comparison with open and minimally invasive sublay technique (eMILOS)

PURPOSE

With robotic surgical devices, an innovative tool has stepped into the arena of minimally invasive hernia surgery. It combines the advantages of open (low recurrence rates and ability to perform complex procedure such as transverse abdominis release) and laparoscopic surgery (low rate of wound and mesh infections, less pain). However, a superiority to standard minimally invasive procedures has not yet been proven. We present our first experiences of robotic mesh repair of incisional hernias and a comparison of our results with open and minimally invasive sublay techniques.

METHODS

A retrospective analysis of all patients who underwent robotic-assisted mesh repair (RAHR) for incisional hernia between April and November 2022 (RAHR group) and patients who underwent open sublay (Sublay group) or eMILOS hernia repair (eMILOS group) between January 2018 and November 2022 was carried out. Patients in the RAHR group were matched 1:2 to patients in the Sublay group by propensity score matching. Patient demographics, preoperative hernia characteristics and cause of hernia, intraoperative variables, and postoperative outcomes were evaluated. Furthermore, a subgroup analysis of only midline hernia was performed.

RESULTS

A total of 21 patients received robotic-assisted incisional hernia repair. Procedures performed included robotic retro-muscular hernia repair (r-RMHR, 76%), with transverse abdominis release in 56% of the cases. In one patient, r-RHMR was combined with robotic inguinal hernia repair. Two patients (10%) were operated with total extraperitoneal technique (eTEP). Robotic-assisted transabdominal preperitoneal hernia repair (r-TAPP) was performed in three patients (14%). Median (range) operating time in the RAHR group was significantly longer than in the sublay and eMILOS group (291 (122-311) vs. 109.5 (48-270) min vs. 123 (100-192) min, respectively, p < 0.001). The meshes applied in the RAHR group were significantly compared to the sublay (mean (SD) 529 ± 311 cm2 vs. 356 ± 231, p = 0.037), but without a difference compared to the eMILOS group (mean (SD) 596 ± 266 cm2). Median (range) length of hospital stay in the RAHR group was significantly shorter compared to the Sublay group (3 (2-7) vs. 5 (1-9) days, p = 0.032), but not significantly different to the eMILOS group. In short term follow-up, no hernia recurrence was observed in the RAHR and eMILOS group, with 9% in the Sublay group. The subgroup analysis of midline hernia revealed very similar results.

CONCLUSION

Our data show a promising outcome after robotic-assisted incisional hernia repair, but no superiority compared to the eMILOS technique. However, RAHR is a promising technique especially for complex hernia in patients with relevant risk factors, especially immunosuppression. Longer follow-up times are needed to accurately assess recurrence rates, and large prospective trials are needed to show superiority of robotic compared to standard open and minimally invasive hernia repair.

Does smoking influence the clinical outcomes of robotic ventral hernia repair? A propensity score matching analysis study

The purpose of this study is to compare the clinical outcomes of robotic ventral hernia repair (RVHR) between smokers and non-smokers. Data for patients undergoing RVHR between 2012 and 2022 were collected. Patients were assigned to either smoking (+) or smoking (-) groups, according to their smoking status in the last 3 months prior to their procedure. Pre-, intra- and postoperative variables including surgical site occurrences (SSO) and infections (SSI), and hernia recurrence were analyzed after a propensity score matching analysis based on the patients' demographics and hernia's characteristics. Each group consisted of 143 patients matched according to their preoperative characteristics. There were no differences in terms of demographics and hernia characteristics. Intraoperative complications occurred at a comparable rate between both groups (p = 0.498). Comprehensive Complication Index® and all complication grades of the Clavien-Dindo classification were similar between both groups. Surgical site occurrences and infections did not differ either [smoking (+) vs. smoking (-): 7.6% vs 5.4%, p = 0.472; 5 vs. 0, p = 0.060, respectively). Rates of SSOs and SSIs that required any intervention (SSOPI) were similar in both groups [smoking (+): 3.1% vs. smoking (-): 0.8%, p = 0.370]. With a mean follow-up of 50 months for the cohort, recurrences rates were also comparable with 7 recorded in the smoking (-) versus 5 in the smoking (+) group (p = 0.215). Our study showed comparable rates of SSOs, SSIs, SSOPIs, and recurrence between smokers and non-smokers following RVHR. Future studies should compare the open, laparoscopic, and robotic approaches in smokers.

Analysis of Factors Associated with Same-Day Discharge After Robotic Transversus Abdominis Release for Incisional Hernia Repairs

Background: Advancement in surgery has shifted numerous procedures to a same-day discharge (SDD) setting. In this study, we evaluated factors related to SDD after robotic transversus abdominis release (rTAR). Materials and Methods: A retrospective analysis of a prospectively maintained hernia databank was performed. Patients who underwent rTAR for incisional hernias were assigned to either the SDD group (length of stay [LOS] <1) or the inpatient group (LOS ≥1 day). Pre-, intra-, and postoperative variables were compared. Predictors of SDD were explored through a logistic regression, and a mediation analysis was performed to assess their effect on the LOS. Results: Out of the 167 patients included, 53 patients were discharged the same day. Age, American Society of Anesthesiologists score, history of coronary artery disease, and wound infection were significantly higher in the inpatient group. Overall, median LOS was 1 (0-2). Postoperative complications did not differ between SDD and inpatient groups except for Clavien-Dindo Grade-II (1 versus 14, respectively; P = .039). Thirty-day readmission rates were comparable (P = .229). A binary logistic regression to predict factors associated with SDD rTAR showed statistical significance in age, operative time, mesh area, and history of wound infection. Mediation analysis showed that mesh size indirectly affected the LOS through the operative time (a = 0.54; b = 0.46; P < .001). An age >46-year-old, an operative time beyond 217 minutes, and a mesh size >475 cm² increased the probability of an inpatient stay (area-under-the-receiver operating characteristic curves: 0.69, 0.81, and 0.82, respectively). Conclusion: The pre- and intraoperative factors associated with SDD rTAR were age, history of wound infection, operative time, and mesh area. Further studies are needed to investigate the appropriateness of discharge decisions while balancing patients' benefits, resource utilization, and costs.

Impact of COVID-19 on clinical outcomes of robotic retromuscular ventral hernia repair

BACKGROUND

The COVID-19 pandemic disrupted the healthcare sector and forced hospitals to limit the number of elective procedures with the goal of reducing overcrowding of wards and thus viral transmission. Recent trends for ventral hernia repair have shifted towards retromuscular techniques, which normally require a longer length of stay. Therefore, the aim of this study is to investigate the impact of the COVID-19 pandemic on clinical outcomes of robotic retromuscular ventral hernia repair (rRVHR).

METHODS

Patients who underwent rRVHR up to 600 days before and after March 10, 2020, were included in this retrospective study and assigned to the pre- or post-COVID group depending on the date of their procedure. Pre-, intra-, and postoperative variables including patients' demographics, hernia characteristics, complications, and hernia recurrence were compared between both groups.

RESULTS

153 (46% female) and 141 (51% female) patients were assigned to the pre- and post-COVID groups respectively. Median age was statistically different between both groups [pre-COVID: 57 (48-68) vs. post-COVID 55 (42-64) years, p = 0.045]. Median hospital length of stay (LOS) was 0 day (0-1) in both groups, and same day discharge were 61% pre-pandemic and 70% post-pandemic (p = 0.09). Mean postoperative follow-up was 39.2 (4.1-93.6) months. In total, 26 pre-COVID patients had postoperative complications, out of which 7 were pulmonary complications, whereas 23 complications were recorded in the post-COVID group, with only 3 pulmonary complications (p = 0.88). Rate of surgical-site events was comparable between both groups, and no recurrences were recorded.

CONCLUSION

This is the first study to describe the impact of the COVID-19 on rRVHR. Hospital LOS was comparable between both groups. Rates of medical and hernia specific complications were not altered by the pandemic.

Can ventral TAPP achieve favorable outcomes in minimally invasive ventral hernia repair? A systematic review and meta-analysis

PURPOSE

The concept of the transabdominal preperitoneal (TAPP) was transferred from the inguinal hernia repair to be adopted in minimally invasive ventral hernia repair (VHR) and since then it has been gaining popularity. However, there are minimal data supporting the ventral TAPP (vTAPP) technique which may lead to reticence in the adoption of this approach. The aim of this meta-analysis was to evaluate the outcomes of patients who received minimally invasive vTAPP for VHR.

STUDY DESIGN

A systematic search was performed of PubMed, Science Direct, Google Scholar and Cochrane Library until July 2022. We selected studies that compared the vTAPP technique with any of other minimally invasive techniques. A meta-analysis was done for the outcomes of perioperative characteristics and postoperative parameters.

RESULTS

A total of 9 studies (1429 patients) were identified. vTAPP was associated with considerable benefit when compared to IPOM. vTAPP was less painful (MD = - 1.01; 95% CI [- 1.39, - 0.64], p < 0.00001), of reduced average cost (MD = - 457.10; 95% CI [- 457.27, - 456.92], p < 0.00001) and decreased SSI (OR = 0.29; 95% [0.09, 0.96], p = 0.04). On the other hand, the vTAPP approach consumed less operative time (MD: - 31.01, 95% CI [- 33.50, - 28.51]), p < 0.00001) and shorter hospital stay than the e-TEP approach.

CONCLUSION

vTAPP appears to be safe and effective procedure for VHR, superior or similar to other minimally invasive techniques for perioperative characteristics and short-term outcomes.

A propensity-score matched analysis of ventral-TAPP vs. laparoscopic IPOM for small and mid-sized ventral hernias. Comparison of perioperative data, surgical outcome and cost-effectiveness

PURPOSE

Laparoscopic techniques have been used and refined in hernia surgery for several years. The aim of this study was to compare an established method such as laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) with ventral Transabdominal Preperitoneal Patch Plasty (ventral-TAPP) in abdominal wall hernia repair.

METHODS

Patient-related data of 180 laparoscopic ventral hernia repairs between June 2014 and August 2020 were extracted from our prospectively maintained database. Of these patients, 34 underwent ventral-TAPP and 146 lap. IPOM. After excluding hernias with a defect size > 5 cm and obtaining balanced groups with propensity-score matching, a comparative analysis was performed in terms perioperative data, surgical outcomes and cost-effectiveness.

RESULTS

Propensity-score matching suggested 27 patients in each of the two cohorts. The statistical evaluation showed that intake of opiates was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.001). The Visual Analogue Scale (VAS) score after lap. IPOM repair was significantly higher at movement (p = 0.008) and at rest (p = 0.023). Also, maximum subjective pain during hospital stay was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.004). No hernia recurrence was detected in either group. The material costs of ventral-TAPP procedure (34.37 ± 0.47 €) were significantly lower than those of the lap. IPOM group (742.57 ± 128.44 € p = 0.001). The mean operation time was 65.19 ± 26.43 min in the lap. IPOM group and 58.65 ± 18.43 min in the ventral-TAPP cohort. Additionally, the length of hospital stay in the lap. IPOM cohort was significantly longer (p = 0.043).

CONCLUSION

Ventral-TAPP procedures represent an alternative technique to lap. IPOM repair to reduce the risk of complications related to intra-peritoneal position of mesh and fixating devices. In addition, our study showed that postoperative pain level, material costs and hospital stay of the ventral-TAPP cohort are significantly lower compared to lap. IPOM patients.

A comparison of outcomes between class-II and class-III obese patients undergoing robotic ventral hernia repair: a multicenter study

BACKGROUND

Morbid obesity has been considered a contraindication to ventral hernia repair (VHR) in the past. However, the relationship between a greater body mass index (BMI) and adverse outcomes has yet to be established in the minimally invasive sphere, particularly with robotics, which may offer an effective surgical option in these high-risk patients. We sought to investigate this relationship by comparing the outcomes of class-II (BMI: 35-39.9 kg/m²) and class-III (BMI: ≥ 40 kg/m²) obese patients after robotic VHR (RVHR).

METHODS

Data were analyzed from two centers and six surgeons who performed RVHR between 2013 and 2020. Patients with a BMI > 35 kg/m² were included in the study. A 1:1 propensity score match (PSM) analysis was conducted to obtain balanced groups and univariate analyses were conducted to compare the two groups across preoperative, intraoperative, and post-operative timeframes. Postoperative complications and morbidity were reported according to the Clavien-Dindo Classification and comprehensive complication index (CCI^®) systems.

RESULTS

From an initial cohort of 815 patients, 228 patients with a mean BMI of 39.7 kg/m² were included in the study. PSM analysis stratified these into 69 patients for each of the class-II and class-III groups. When comparing matched groups, there were no differences in any of the variables across all timeframes, except for a higher rate of Polytetrafluoroethylene (PTFE)-based mesh use in the class-III group (39.1% vs 17.4%, p = 0.008). The estimated recurrence-free time was 76.4 months (95% CI = 72.5-80.4) for the class-II group and 80.4 months (95% CI = 78-82.8) for the class-III group.

CONCLUSION

This multicenter study showed no difference in outcomes after RVHR between matched class-II and class-III obese patients.

Short-term outcomes of minimally invasive retromuscular ventral hernia repair using an enhanced view totally extraperitoneal (eTEP) approach: systematic review and meta-analysis

Background

The enhanced view totally extraperitoneal (eTEP) approach is becoming increasingly more widely accepted as a promising technique in the treatment of ventral hernia. However, evidence is still lacking regarding the perioperative, postoperative and long-term outcomes of this technique. The aim of this meta-analysis is to summarize the current available evidence regarding the perioperative and short-term outcomes of ventral hernia repair using eTEP.

Study design

A systematic search was performed of PubMed, EMBASE, Cochrane Library and Web of Science electronic databases to identify studies on the laparoscopic or robotic-enhanced view totally extraperitoneal (eTEP) approach for the treatment of ventral hernia. A pooled meta-analysis was performed. The primary end point was focused on short-term outcomes regarding perioperative characteristics and postoperative parameters.

Results

A total of 13 studies were identified involving 918 patients. Minimally invasive eTEP resulted in a rate of surgical site infection of 0% [95% CI 0.0–1.0%], a rate of seroma of 5% [95% CI 2.0–8.0%] and a rate of major complications (Clavien–Dindo III–IV) of 1% [95% CI 0.0–3.0%]. The rate of intraoperative complications was 2% [95% CI 0.0–4.0%] with a conversion rate of 1.0% [95% CI 0.0–3.0%]. Mean hospital length of stay was 1.77 days [95% CI 1.21–2.24]. After a median follow-up of 6.6 months (1–24), the rate of recurrence was 1% [95% CI 0.0–1.0%].

Conclusion

Minimally invasive eTEP is a safe and effective approach for ventral hernia repair, with low reported intraoperative complications and good outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02557-8.

Intraperitoneal versus extraperitoneal mesh in minimally invasive ventral hernia repair: a systematic review and meta-analysis

PURPOSE

The ideal location for mesh placement in minimally invasive ventral hernia repair (VHR) is still up for debate. We undertook a systematic review and meta-analysis (SRMA) to evaluate the outcomes of patients who received intraperitoneal mesh versus those that received extraperitoneal mesh in minimally invasive VHR.

METHODS

We searched PubMed, EMBASE, Cochrane, and Scopus from inception to May 3, 2021. We selected studies comparing intraperitoneal mesh versus extraperitoneal mesh placement in minimally invasive VHR. A meta-analysis was done for the outcomes of surgical site infection (SSI), seroma, hematoma, readmission, and recurrence. A subgroup analysis was conducted for a subset of studies comparing patients who have undergone intraperitoneal onlay mesh (IPOM) versus extended totally extraperitoneal approach (e-TEP).

RESULTS

A total of 11 studies (2320 patients) were identified. We found no statistically significant difference between patients who received intraperitoneal versus extraperitoneal mesh for outcomes of SSI, seroma, hematoma, readmission, and recurrence [(RR 1.60, 95% CI 0.60-4.27), (RR 1.39, 95% CI 0.68-2.81), (RR 1.29, 95% CI 0.45-3.72), (RR 1.40, 95% CI 0.69-2.86), and (RR 1.22, 95% CI 0.22-6.63), respectively]. The subgroup analysis had findings similar to the overall analysis.

CONCLUSION

Based on short-term results, extraperitoneal mesh does not appear to be superior to intraperitoneal mesh in minimally invasive ventral hernia repair. The choice of mesh location should be based on the current evidence, surgeon, and center experience as well as individualized to each patient.

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.

A novel approach for the treatment of Morgagni hernias: robotic transabdominal preperitoneal diaphragmatic hernia repair

PURPOSE

We introduce a novel approach to the surgical repair of Morgagni hernias (MHs) utilizing the robotic transabdominal preperitoneal repair (rTAPP) approach. Borrowed from our previous and robust experience with rTAPP repairs for hernias of the anterior abdominal wall, this technique boasts the benefits of hernia sac reduction, the use of an uncoated mesh in an extraperitoneal plane, and minimal fixation leading to lower postoperative pain relative to other approaches.

METHODS

To evaluate the effectiveness of this novel approach, five consecutive symptomatic Morgagni hernias (MHs) were repaired with the rTAPP approach. The size of the defect, mesh size, length of stay, follow-up imaging, and follow-up complications were documented for comparison.

RESULTS

The size of the MH defects ranged from 4 × 6 cm to 5 × 10 cm. LOS was an average of 1.2 days. Two out of the five patients underwent concomitant repair of a lower abdominal hernias (one Spigelian hernia, and one indirect inguinal hernia). Outpatient follow-up from surgery ranged anywhere from 6 months to 4 years, with most patients receiving follow-up after 1 year. Four out of the five patients received follow-up CT scans to confirm the absence of hernia recurrence. One patient experienced an incisional hernia from the midline 12-mm port site which was repaired 1 year after.

CONCLUSION

We propose a new technique for a minimally invasive strategy to treat these complex hernias utilizing an rTAPP technique resulting in minimal length of stay and a durable result in long-term follow-up. The benefits of repair, which include minimal postoperative pain, minimal length of stay, and cost-effective prosthetic mesh hidden from the visceral contents, are consistent with the author's experience for rTAPP repairs for hernias of the anterior abdominal wall.

Learning curve of robotic transversus abdominis release in ventral hernia repair: a cumulative sum (CUSUM) analysis

BACKGROUND

Despite heightened interest in robotic transversus abdominis release (rTAR), concerns over its steep learning curve (LC) and associated challenges may limit its adoption. This study defines the operative time and morbidity-based LC of a single surgeon's experience with rTAR.

METHODS

A retrospective analysis of patients undergoing rTAR over an 8-year period was conducted. Consecutive ventral and incisional hernia repairs were stratified into four sub-categories based on bilaterality and complexity, with complex hernias being defined as those > 10 cm. Cumulative sum analyses (CUSUM) were used to evaluate skin-to-skin time and morbidity LCs.

RESULTS

This study included a total of 156 rTARs with a mean skin-to-skin time of 222.8 min. Mean skin-to-skin times (min) for sub-categories were as follows: unilateral non-complex (137.6), bilateral non-complex (206.8), unilateral complex (241.9), and bilateral complex (298.6). The CUSUM-LC was obtained by summing the differences between each procedure's operative time and its sub-category mean, revealing a quadratic best-fit line maximum at case 49 and a transition point between early and late phases at case 75. Although skin-to-skin times between early and late phases did not differ significantly (235.3 vs 211.2, respectively; p = 0.12), a significant difference was found in console times. Overall postoperative complications also decreased significantly from early to late phases (41.3% vs 25.9%; p = 0.041). Postoperative complications were predicted by a history of wound infection (c = 0.61).

CONCLUSIONS

This study reveals that the rTAR LC was overcome between 49 and 75 cases, after which, console time and postoperative complications decreased significantly.

[Current robotic ventral hernia surgery exemplified by 50 consecutive patients]

BACKGROUND

In recent years there has been a rise in robotic techniques and approaches regarding hernia repair with extraperitoneal mesh placement.

METHODS

A retrospective analysis of the first 50 patients who underwent robotic ventral hernia repair between May 2019 and November 2020 at the department of general surgery of the Kempten Clinic was performed.

RESULTS

This case series consisted of 36 incisional hernias, 12 primary hernias (8 umbilical and 3 epigastric hernias in combination with a diastasis recti abdominis as well as 1 Spigelian hernia) and 2 parastomal hernias. A complete closure of the hernia was achieved in all cases. Extraperitoneal mesh placement in the retromuscular or preperitoneal space was achieved in 98 % of the ventral procedures. We used an extraperitoneal approach with retromuscular mesh implantation (r-eTEP= robotic enhanced view total extraperitoneal plasty) in 22 cases, 3 of those along with a transversus abdominis release (r-eTAR= robotic extraperitoneal transversus abdominis release) and 26 operations were carried out transperitoneally. These included 11 preperitoneal (r-vTAPP= robotic ventral TAPP), 7 retrorectus (TARUP= robotic transabdominal retromuscular umbilical prosthetic hernia repair) and 1 intraperitoneal onlay mesh placements (r-IPOM= robotic intraperitoneal onlay mesh) as well as 7 transperitoneal transversus abdominis releases with retromuscular mesh placement. The 2 parastomal hernias were treated with an intraperitoneal 3D funnel mesh. After the initial treatment of smaller hernias the indications could be rapidly extended to complex hernias in 38 % of this case series. One conversion to an open operation was necessary due to technical problems in closing the posterior rectus sheath. The complication rate was 12 % and the reintervention rate 4 %.

CONCLUSION

Robotic surgery of ventral hernia is safe and effective. Even complex hernias can be treated minimally invasively with closure of the hernia defect and extraperitoneal mesh placement.

Learning Curve of Robotic Rives-Stoppa Ventral Hernia Repair: A Cumulative Sum Analysis

Background: Robotic Rives-Stoppa ventral hernia repair (rRS-VHR) is a minimally invasive technique that incorporates extraperitoneal mesh placement, using either transabdominal or totally extraperitoneal access. An understanding of its learning curve and technical challenges may guide and encourage its adoption. We aim at evaluating the rRS-VHR learning curve based on operative times while accounting for adverse outcomes. Materials and Methods: We conducted a retrospective analysis of patients undergoing rRS repair for centrally located ventral and incisional hernias. A single surgeon operative time-based cumulative sum (CUSUM) analysis learning curve was created, and a composite outcome was used for risk-adjusted CUSUM (RA-CUSUM). Results: Eighty-one patients undergoing rRS-VHR were included. A learning curve was created by using skin-to-skin times. Accordingly, patients were grouped into three phases. The mean skin-to-skin time was 72.2 minutes, and there was a significant decrease in skin-to-skin times throughout the learning curve (Phase-I: 86.4 minutes versus Phase-III: 63.8 minutes; P = .001), with a gradual decrease after 29 cases. Eleven patients experienced adverse composite outcomes, which were used to create a RA-CUSUM graph. Results showed the highest adverse outcome rates in Phase-II, with a gradual decrease in risk-adjusted operative times after 51 cases. Conclusions: Consistently decreasing operative times and adverse outcome rates in rRS-VHR was observed after the completion of 29 and 51 cases, respectively. Future studies that provide group learning curves for this procedure can deliver more generalizable results in terms of its performance rates.

Learning Curve in Robotic Primary Ventral Hernia Repair Using Intraperitoneal Onlay Mesh: A Cumulative Sum Analysis

BACKGROUND

Cumulative sum (CUSUM) learning curves (LCs) are useful to analyze individual performance and to evaluate the acquisition of new skills and the evolution of those skills as experience is accumulated. The purpose of this study is to present a CUSUM LC based on the operative times of robotic intraperitoneal onlay mesh (rIPOM) ventral hernia repair (VHR) and identify differences observed throughout its phases.

MATERIALS AND METHODS

Patients who underwent rIPOM repair for elective, midline, and primary hernias were included. All procedures were performed exclusively by one surgeon within a 5-year period. CUSUM and risk-adjusted CUSUM were used to visualize the LC of rIPOM-VHR, based on operative times and complications. Once groups were obtained, univariate comparisons were performed.

RESULTS

Of the 90 rIPOM repairs, 25, 40, and 25 patients were allocated using a CUSUM analysis to the early, middle, and late phases, respectively. In terms of skin-to-skin times, the middle phase has a mean duration of 23 minutes shorter than the early phase (P<0.001), and the late phase has a mean duration 34 minutes shorter than the early phase (P<0.001). A steep decrease in off-console time was observed, with a 10-minute difference from early to middle phases. A consistent and gradual decrease in operative times was observed after completion of 36 cases, and a risk-adjusted CUSUM revealed improving outcomes after 55 cases.

CONCLUSIONS

This study demonstrates and elucidates interval improvement in operative efficiency in rIPOM-VHR. Consistently decreasing operative times and simultaneous accumulated complication rates were observed after the completion of 55 cases.

Comparison of Midterm Outcomes Between Open and Robotic Emergent Ventral Hernia Repair

Background. There are no studies on the role of robotics in emergency ventral hernia repair (EVHR). We aimed to compare outcomes of robotic EVHR (REVHR) and open (OEVHR). Methods. We performed a retrospective study of EVHRs performed between 2013 and 2019. Patients who underwent ventral hernia repair in an elective setting and patients who had concomitant non-abdominal wall procedures were excluded. Pre-, intra-, and postoperative variables were compared. Univariate and multivariate analyses were performed. Results. In all, 43 patients underwent OEVHR as compared to 35 patients who underwent REVHR. The patients in both groups were similar in terms of hernia etiology as well as Acute Physiology and Chronic Health Evaluation (APACHE-II) and the Sequential Organ Failure Assessment (SOFA) scores. Mean operative times for the robotic group were almost 2-fold compared with those of the open group (139 minutes vs 70 minutes, respectively; P < .001). Median length of stay (LOS) did not differ between the groups (3 days for both groups; P = .488). Major complications (P = .001), morbidity scores (P = .006), surgical site events (SSEs) (P = .045), and procedural interventions (P = .020) were found higher in the open group. No differences in freedom of recurrence were found (P = .662). Multivariate logistic regression analysis showed that open repair was associated with a 4-fold risk for the development of complications as compared to robotic repair (P = .025; odds ratio (OR) = 4, 95% confidence interval (CI) = 1.193-13.444). Conclusion. Compared to OEVHR, REVHR resulted in longer operative times and lower morbidity, including SSEs and related interventions. However, neither LOS nor recurrence differed between the groups.

Perioperative and midterm outcomes of emergent robotic repair of incarcerated ventral and incisional hernia

The literature surrounding emergent robotic ventral hernia repair (RVHR) is scarce. We aimed to present the results of 6 years of experience of RVHR in the emergency setting. Data were retrospectively analyzed from patients who underwent RVHR in an emergent setting between 2013 and 2019. Complications were assessed with the Clavien-Dindo (CD) and Comprehensive Complication Index (CCI^®) scoring systems. Kaplan-Meier's time-to-event analysis was performed to calculate freedom-of-recurrence. Out of 589 patients who underwent RVHR, 34 patients were included. Median APACHE-II scores were 6.5. The average skin-to-skin time was 139 min. 7/34(20.5%) patients experienced minor complications (CD-grades I-II) and 4/34 (11.7%) patients experienced major complications (CD-grades III-IV). CCI^® scores ranged from 0-42.4. Only one (2.9%) patient experienced hernia recurrence. The mean postoperative follow-up was 20.5 (range 1.6-56.3) months. Emergent RVHR showed promising results in terms of midterm outcomes and overall feasibility. RVHR appears to be effective in emergency settings, however, further multicenter studies with long-term follow-up are needed.

Transabdominal (TA) versus totally extraperitoneal (TEP) robotic retromuscular ventral hernia repair: a propensity score matching analysis

PURPOSE

Retromuscular mesh placement positioning utilizing the robotic platform can be performed using either a transabdominal or an extraperitoneal approach. The aim of this study is to compare short-term outcomes of robotic transabdominal access retromuscular (rTA-RM) repair and robotic totally extraperitoneal access retromuscular (rTEP-RM) repair for ventral hernias METHODS: Patients who underwent robotic retromuscular repair between February 2013-October 2019 were included in the study. A one-to-one propensity score matching (PSM) analysis was conducted to obtain two balanced groups. A comparative analysis was performed in terms of perioperative and early post-operative outcomes.

RESULTS

A total of 214 patients were included for PSM analysis. 82 patients were allocated into each study group. Operative times were longer in rTA-RM group. Adhesiolysis was more frequently required in the rTA-RM group. Intra-operative complications occurred more frequently in patients who underwent rTA-RM repair (p = 0.120; 4.9% in rTA-RM vs. 0% in rTEP-RM). The rate of major complications during the first 90 days did not differ between groups (p = 0.277; 7.3% vs. 2.4%, respectively). The proportion of patients with minor perioperative complications was statistically higher in the rTA-RM group than the rTEP-RM group (p = 0.003; 30.5% vs. 11%, respectively). Overall rate of surgical site events was higher in the rTA-RM group than the rTEP-RM group (p = 0.049; 17.1% vs. 6.1%, respectively). Seroma frequency was higher after rTA-RM repair (p = 0.047; 13.4% vs. 3.7%).

CONCLUSION

Our data suggest that rTEP-RM repair was associated with shorter surgery duration and improved early post-operative outcomes in comparison with rTA-RM repair.

Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis

Purpose

rTAPP-VHR is a novel technique which may be added to a surgeon’s armamentarium. We aim to evaluate the robotic transabdominal preperitoneal ventral hernia repair (rTAPP-VHR) learning curve based on operative times while accounting for peritoneal flap integrity.

Methods

We performed a retrospective analysis of a database collected over a 7-year period. Patients with primary ventral hernias were included and a cumulative sum analysis(CUSUM) was used to create learning curves for three subsets of operative times. A risk-adjusted CUSUM (RA-CUSUM) accounted for repair quality based on peritoneal flap completeness. The flap was considered as incomplete when peritoneal gaps were unable to be closed.

Results

105 patients undergoing rTAPP-VHR were included. Learning curves were created for skin-to-skin, console, and off-console times. Patients were divided into three phases. In terms of skin-to-skin times, both phase 2&3 had a mean 11 min shorter than that of phase 1 (p = 0.0498, p = 0.0245, respectively), with a steady decrease after forty-six cases. An incomplete peritoneal flap was noted in 25/36 patients in phase 1, as compared to 5/24 and 5/45 patients in phase 2&3, respectively. When risk-adjusted for peritoneal flap completeness, gradually decreasing skin-to-skin times were observed after sixty-one cases. In terms of off-console times, the mean across three phases was 14 min, with marked improvement after forty-three cases.

Conclusions

Forty-six cases were needed to achieve steadily decreasing operative times. We can assume that ensuring good-quality repairs, through maintenance of peritoneal flap integrity, was gradually improved after sixty-one cases. Moreover, familiarization with port placements and robotic docking was accomplished after forty-three cases.

A comparison of robotic mesh repair techniques for primary uncomplicated midline ventral hernias and analysis of risk factors associated with postoperative complications

PURPOSE

We aim to compare short-term outcomes of robotic intraperitoneal onlay (rIPOM), transabdominal preperitoneal (rTAPP) and retromuscular (rRM) repair for uncomplicated midline primary ventral hernias (PVH) and determine risk factors associated with postoperative complications.

METHODS

The three groups were compared in terms of pre-, intra-, and post-operative variables. Postoperative complications were assessed using previously validated classifications. Univariate analyses were conducted to determine which variables influence postoperative complications (up to 90 days), followed by a multivariate regression analysis revealing statistically important risk factors.

RESULTS

A total of 269 patients who underwent robotic PVH repair patients were grouped as rIPOM (n = 90), rTAPP (n = 108), and rRM (n = 71). rRM repair allowed for the use of larger-sized meshes for larger defects; however, it was associated with higher-grade complications. rTAPP repair resulted in the lowest morbidity and offered the highest mesh-to-defect ratio for smaller-sized hernias. Operative time for the rRM group was longer. The rIPOM group had a higher morbidity, likely due to higher frequency of minor complications, as compared to rTAPP and rRM groups. Multivariate regression analysis revealed that coronary artery disease, absence of defect closure, intraperitoneally placed mesh, and skin-to-skin time (minutes) were significantly associated with postoperative complications.

CONCLUSION

Robotic PVHR contributes multiple techniques to a surgeon's armamentarium, such as IPOM, TAPP, and RM mesh placements. Patient characteristics as well as the potential consequences of each technique need to be taken into consideration when deciding the appropriate approach for the repair of primary uncomplicated midline ventral hernias.

Are elderly patients at high risk for postoperative complications after robotic ventral hernia repair? A propensity score matching analysis

BACKGROUND

The purpose of this study was to compare the elderly (≥65 years) and non-elderly groups regarding perioperative outcomes after robotic ventral hernia repair (RVHR).

METHODS

A one-to-one propensity score matching (PSM) analysis was conducted to obtain balanced groups. Postoperative complications including surgical site events (SSEs) (surgical site infections [SSIs], surgical site occurrences [SSOs], and surgical site occurrence procedural interventions [SSOPIs]) were compared.

RESULTS

The unmatched sample included 521 patients. Of these, 139 patients were elderly (range 65-94 years). After PSM, 98 patients were assigned to each group. Intraoperative variables were similar. The non-elderly and elderly groups experienced similar complication rates during the first 90 days. SSEs (SSIs, SSOs, and SSOPIs) did not differ between the two groups.

CONCLUSION

RVHR is safe and efficacious for patients aged 65 and over. Age alone need not be a prohibitive factor in determining patient selection for RVHR; however, it would be more beneficial to take into consideration other patient-related factors as well.

Robotic intraperitoneal onlay versus totally extraperitoneal (TEP) retromuscular mesh ventral hernia repair: A propensity score matching analysis of short-term outcomes

BACKGROUND

Short-term outcomes of robotic intraperitoneal onlay mesh(rIPOM) versus robotic totally extraperitoneal retromuscular mesh(rTEP-RM) ventral hernia repair were compared.

METHODS

A retrospective review of prospectively collected data of patients was conducted. A one-to-one propensity score matching(PSM) analysis was performed to achieve two well-balanced groups in terms of preoperative variables. A univariate and multivariate analysis were conducted to determine factors influencing post-operative outcomes.

RESULTS

Of 291 rIPOM and rTEP-RM procedures, 68 patients were assigned to each group after PSM. Operative times were longer for the rTEP-RM group. Adhesiolysis was more frequently required in rIPOM. The rTEP-RM allowed for a greater mesh-to-defect ratio. The rate of overall perioperative complications, Clavien-Dindo grades, and surgical site events were higher for the rIPOM group than the rTEP-RM group. The Comprehensive Complication Index® morbidity scores were lower in favor of rTEP-RM group. Adhesiolysis, rIPOM, and craniocaudal defect size were predictors for post-operative complications.

CONCLUSION

Robotic TEP-RM repair has better early postoperative outcomes for ventral hernias, suggesting that it may be preferable over robotic IPOM repair. Further studies with longer follow-up are needed.

Propensity score matching analysis of short-term outcomes in robotic ventral hernia repair for patients with a body mass index above and below 35 kg/m2

OBJECTIVE

The purpose of this study was to compare perioperative complications after robotic ventral hernia repair between patients with non-obese, class-I obesity with those with class-II or class-III obesity.

BACKGROUND

Obesity is a growing epidemic and is considered as an independent risk factor for a multitude of perioperative complications. Laparoscopic ventral hernia repair has been shown as a safe and feasible approach in population with elevated body mass index (BMI). This study compared overall perioperative complications and surgical site events (SSEs) after robotic ventral hernia repair (RVHR) between patients with a BMI 35 kg/m² or more and patients with a BMI lower than 35 kg/m².

METHODS

A retrospective cohort analysis was conducted with one-to-one propensity score matching (PSM) method to obtain balanced groups evaluating patients who underwent RVHR between February 2012 and June 2019 in a single institution. Preoperative, intraoperative, and postoperative variables were reviewed. Postoperative complications and morbidity were assessed using the Clavien-Dindo classification and comprehensive complication index (CCI^®) score system. SSEs were compared.

RESULTS

Our unmatched sample included 526 patients with an average BMI of 31.2 kg/m². Of these, 29.8% (n = 160) patients were in high-BMI group (range 35-59.2). After PSM, 142 patients were assigned to each group. Both groups experienced similar complication rates during 90 days. Clavien-Dindo grades, CCI^® scores, and SSEs did not differ between the two groups.

CONCLUSION

RVHR in class-II and class-III obese patients is safe, feasible, and effective. In addition to this, it has comparable short-term outcomes with those non-obese and class-I obese patients.

Lateral approach totally extraperitoneal (TEP) robotic retromuscular ventral hernia repair

BACKGROUND

The enhanced (or extended) view total extraperitoneal (TEP) access that was initially described for laparoscopic inguinal hernia repair has been applied to first laparoscopic and now robotic retromuscular ventral hernia repair (RRVHR). However, a 'dynamic' port setup that is based on the area of interest is preferred by most surgeons. In this study, we present our center's early operative outcomes after utilizing a lateral approach TEP-access RRVHR with and without transversus abdominis release (TAR).

METHOD

An evaluation of a prospectively maintained database of hernia patients was conducted identifying patients who underwent a lateral approach TEP-access RRVHR between February 2013 and April 2019. The lateral approach TEP-access RRVHR was described. Patient demographics, intraoperative and postoperative variables were reviewed. Preoperative and postoperative results were presented according to recommended classification systems by European Hernia Society.

RESULTS

Fifty-two patients who underwent a lateral approach TEP-access RRVHR were included in this study. A lateral dock setup was utilized for all patient who had a midline defect, as well as a lateral defect. The mean console time was 121.6 min., skin-to-skin time was 138.5 min. There was no intraoperative complication or conversion. The mean hospital length of stay was 0.71 day. During the mean 6.5 months follow-up period, no hernia recurrence arose.

CONCLUSION

The lateral approach TEP-access RRVHR with and without TAR is a reproducible technique. Feasibility of this approach needs to be demonstrated by other surgeons familiar with retromuscular hernia repair in addition to long-term follow up.