Incisional Hernia Repair

Open versus robotic retromuscular ventral hernia repair: outcomes of the ORREO prospective randomized controlled trial

BACKGROUND

Robotic retromuscular ventral hernia repair (rRMVHR) potentially combines the best features of open and minimally invasive VHR: myofascial release with abdominal wall reconstruction (AWR) with the lower wound morbidity of laparoscopic VHR. Proliferation of this technique has outpaced the data supporting this claim. We report 2-year outcomes of the first randomized controlled trial of oRMVHR vs rRMVHR.

METHODS

Single-center randomized control trial of open vs rRMVHR. 100 patients were randomized (50 open, 50 robotic). We included patients > 18 y/o with hernias 7-15 cm with at least one of the following: diabetes, chronic obstructive pulmonary disease (COPD), body mass index (BMI) ≥ 30, or current smokers. Primary outcome was occurrence of a composite outcome of surgical site infection (SSI), non-seroma surgical site occurrence (SSO), readmission, or hernia recurrence. Secondary outcomes were length of stay, any SSI or SSO, SSI/SSOPI, operative time, patient reported quality of life, and cost. Analysis was performed in an intention-to-treat fashion. Study was funded by a grant from Society of American Gastrointestinal and Endoscopic Surgeons.

RESULTS

90 patients were available for 30-day and 62 for 2-year analysis (rRMVHR = 46 and 32, oRMVHR = 44 and 30). Hernias in the open group were slightly larger (10 vs 8 cm, p = 0.024) and more likely to have prior mesh (36.4 vs 15.2%; p = 0.030), but were similar in length, prior hernia repairs, mesh use, and myofascial release. There was no difference in primary composite outcome between oRMVHR and rRMVHR (20.5 vs 19.6%, p = 1.000). Median length of stay was shorter for rRMVHR (1 vs 2 days; p < 0.001). All patients had significant improvement in quality of life at 1 and 2 years. Other secondary outcomes were similar.

CONCLUSION

There is no difference in a composite outcome including SSI, SSOPI, readmission, and hernia recurrence between open and robotic RMVHR.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incisional Hernia: A Surgical Complication or Medical Disease?

Incisional hernia (IH) is a frequent complication following abdominal surgery. The development of IH could be more sophisticated than a simple anatomical failure of the abdominal wall. Reported IH incidence varies among studies. This review presented an overview of definitions, molecular basis, risk factors, incidence, clinical presentation, surgical techniques, postoperative care, cost, risk prediction tools, and proposed preventative measures. A literature search of PubMed was conducted to include high-quality studies on IH. The incidence of IH depends on the primary surgical pathology, incision site and extent, associated medical comorbidities, and risk factors. The review highlighted inherent and modifiable risk factors. The disorganisation of the extracellular matrix, defective fibroblast functions, and ratio variations of different collagen types are implicated in molecular mechanisms. Elective repair of IH alleviates symptoms, prevents complications, and improves the quality of life (QOL). Recent studies introduced risk prediction tools to implement preventative measures, including suture line reinforcement or prophylactic mesh application in high-risk groups. Elective repair improves QOL and prevents sinister outcomes associated with emergency IH repair. The watchful wait strategy should be reviewed, and options should be discussed thoroughly during patients' counselling. Risk stratification tools for predicting IH would help adopt prophylactic measures.

Minimally invasive approach to incisional hernia in elective and emergency surgery: a SICE (Italian Society of Endoscopic Surgery and new technologies) and ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) online survey

Minimally invasive abdominal wall surgery is growing worldwide, with a constant and fast improvement of surgical techniques and surgeons' confidence in treating both primary and incisional hernias (IH). The Italian Society of Endoscopic Surgery and new technologies (SICE) and the ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) worked together to investigate state of the art in IH treatment in elective and emergency settings in Italy. An online open survey was designed, and Italian surgeons interested in abdominal wall surgery were invited to fill out a 20-point questionnaire on IH surgical procedures performed in their departments. Surgeons were asked to express their points of view on specific questions about technical and clinical variables in IH treatment. Preferred approach in elective IH surgery was minimally invasive (59.7%). Open surgery was the preferred approach in 40.3% of the responses. In emergency settings, open surgery was the preferred approach (65.4%); however, 34.5% of the involved surgeons declare to prefer the laparoscopic/endoscopic approach. Most respondents opted for conversion to open surgery in case of relevant surgical field contamination, with a non-mesh repair of abdominal wall defects. Among those that used the laparoscopic approach in the emergent setting, the majority (74%) used the size of the defect of 5 cm as a decisional cut-off. The spread of minimally invasive approaches to IH repair in emergency surgery in Italy is gaining relevance. Code-sharing through scientific societies can improve clinical practice in different departments and promote a tailored approach to IH surgery.

Follow-The-Leader Mechanisms in Medical Devices: A Review on Scientific and Patent Literature

Conventional medical instruments are not capable of passing through tortuous anatomy as required for natural orifice transluminal endoscopic surgery due to their rigid shaft designs. Nevertheless, developments in minimally invasive surgery are pushing medical devices to become more dexterous. Amongst devices with controllable flexibility, so-called Follow-The-Leader (FTL) devices possess motion capabilities to pass through confined spaces without interacting with anatomical structures. The goal of this literature study is to provide a comprehensive overview of medical devices with FTL motion. A scientific and patent literature search was performed in five databases (Scopus, PubMed, Web of Science, IEEExplore, Espacenet). Keywords were used to isolate FTL behavior in devices with medical applications. Ultimately, 35 unique devices were reviewed and categorized. Devices were allocated according to their design strategies to obtain the three fundamental sub-functions of FTL motion: steering, (controlling the leader/end-effector orientation), propagation, (advancing the device along a specific path), and conservation (memorizing the shape of the path taken by the device). A comparative analysis of the devices was carried out, showing the commonly used design choices for each sub-function and the different combinations. The advantages and disadvantages of the design aspects and an overview of their performance were provided. Devices that were initially assessed as ineligible were considered in a possible medical context or presented with FTL potential, broadening the classification. This review could aid in the development of a new generation of FTL devices by providing a comprehensive overview of the current solutions and stimulating the search for new ones.

Hernia Defect Closure With Barbed Suture: An Assessment of Patient-reported Outcomes in Extraperitoneal Robotic Ventral Hernia Repair

BACKGROUND

Primary closure of a fascial defect during ventral hernia repair is associated with lower rates of recurrence and better patient satisfaction compared with bridging repairs. Robotic surgery offers enhanced ability to close these defects and this has likely been aided by the use of barbed suture. The goal of this study was to evaluate the perioperative safety and the long-term outcomes for the use of barbed suture for the primary closure of hernia defects during robotic ventral hernia repair (rVHR) with mesh.

METHODS

This is a retrospective study of adult patients who underwent rVHR with the use of a barbed suture for fascial defect closure from August 2018 to August 2020 in an academic center. All the patients included were queried by phone to complete a quality of life assessment to assess patient-reported outcomes (PROs). Subjective sense of a bulge and pain at the previous hernia site has been shown to correlate with hernia recurrence. These questions were used in conjunction with a Hernia-related Quality of Life Survey (HerQles) score to assess a patient's quality of life.

RESULTS

A total of 81 patients with 102 hernias were analyzed. Sixty patients (74%) were successfully reached and completed the PRO form at median postoperative day 356 (range: 43 to 818). Eight patients (13% of patients with PRO data) claimed to have both a bulge and pain at their previous hernia site, concerning for possible recurrence. Median overall HerQLes score was 82 [Interquartile Range (IQR): 54 to 99]. Patients with a single hernia defect, when compared with those with multiple defects, had a lower rate of both a bulge (15% vs. 30%) and symptoms (33% vs. 48%), as well as a higher median HerQLes score (85 vs. 62) at the time of PRO follow-up. Patients with previous hernia repair had a lower median HerQLes score of 65 (IQR: 43 to 90) versus 88 (IQR: 62-100). These patients also had a higher rate of sensing a bulge (29% vs. 18%), whereas a sense of symptoms at the site was less (33% vs. 44%).

CONCLUSIONS

Barbed suture for fascial defect closure in rVHR was found to be safe with an acceptable rate of possible recurrence by the use of PRO data. Patients with multiple hernias and previous repairs had a higher likelihood of recurrence and a lower quality of life after rVHR.

Body Mass Index impact on Extended Total Extraperitoneal Ventral Hernia Repair: a comparative study

PURPOSE

Obesity is a risk factor for developing abdominal wall hernias and is associated with major postoperative complications, such as surgical site infection, delayed wound healing and recurrent hernia. Therefore, treating incisional hernia in this patient subgroup is a challenge.

METHODS

We conducted a comparative, prospective study on patients who underwent primary ventral hernia surgery or incisional hernia surgery through the extended totally extraperitoneal pathway, with body mass indices (BMIs) ≤ 30 (no obesity) and BMI > 30 (with obesity). We collected demographic data, preoperative and intraoperative variables, complication and recurrence rate, hospital stay and follow-up as postoperative data.

RESULTS

From May 2018 to December 2020, 74 patients underwent this surgery, 38 patients without obesity and 36 with obesity. The median area of the hernia defect measured by CT was 57 cm² and 93 cm² in patients without and with obesity, respectively (p = 0.012). The median follow-up was 16 months. One patient without obesity experienced some postoperative complication compared with four patients with obesity (p > 0.05). No patient without obesity had recurrent hernia compared with two patients with obesity (p > 0.05).

CONCLUSIONS

There were statistically significant differences between patients with and without obesity in the size of the hernia defect. However, there were no significant differences in terms of complications, hospital stay, postoperative pain or relapses. Therefore, the minimally invasive completely extraperitoneal approach for patients with obesity appears to be a safe procedure despite our study limitations. Studies with longer follow-ups and a greater number of patients are needed.

Incisional Hernia Repaired Using Thigh Muscle Fascia After Kidney Transplantation: A Case Report

BACKGROUND

Although monofilament mesh-based repair is a safe and effective procedure for incisional hernia (IH) in organ transplant patients, there is no definite evidence of IH treatment for patients with graft rejection and enhanced immunosuppressive therapy. We report a successful case of large IH repair using an autologous thigh muscle fascia sheet in a kidney transplant patient.

CASE PRESENTATION

A 69-year-old man had IH from the incision of kidney transplantation, which was performed 6 years ago. He had a large right lower abdominal distension hanging down to the inguinal portion. A computed tomography scan revealed a large IH with a maximum abdominal defect diameter of 15 cm. The hernia sac contained the intestine, colon, and transplanted kidney, which had pulled out along with the retroperitoneum and protruded into the abdominal wall. He had chronic active acute antibody-mediated rejection, which required frequent steroid pulse therapy and additional or adjusted immunosuppressive drugs. After total circumferential exposure of the hernia sac and abdominal fascia, the abdominal wall defect was closed using a horizontal mattress suture. The sutured line was covered with a thigh muscle fascia sheet harvested from the patient's right femur and attached to the closed fascia. He was discharged on postoperative day 13 without any complications, and no IH recurrence was observed 10 months after surgery.

CONCLUSIONS

Hernia repair using autologous tissue could be a treatment option for post-transplant IH with a higher risk of infection.

Excess Body Weight and Abdominal Hernia

Background

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

Summary

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

Key Messages

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

Robotic-assisted, laparoscopic, and open incisional hernia repair: early outcomes from the Prospective Hernia Study

PURPOSE

To provide a comparative analysis of short-term outcomes after open, laparoscopic, and robotic-assisted (RAS) ventral incisional hernia (VIH) repairs that include subject-reported pain medication usage and hernia-related quality of life (QOL).

METHODS

Subjects were ≥ 18 years old and underwent elective open, laparoscopic or RAS VIH repair without myofascial release. Perioperative clinical outcomes through 30 days were analyzed as were prescription pain medication use and subject-reported responses to the HerQLes Abdominal QOL questionnaire. Observed differences in baseline characteristics were controlled using a weighted propensity score analysis to obviate potential selection bias (inverse probability of treatment weighting, IPTW). A p value < 0.05 was considered statistically significant.

RESULTS

Three hundred and seventy-one subjects (RAS, n = 159; open, n = 130; laparoscopic, n = 82) were enrolled in the study across 17 medical institutions within the United States. Operative times were significantly different between the RAS and laparoscopic groups (126.2 vs 57.2, respectively; p < 0.001). Mean length of stay was comparable for RAS vs laparoscopic (1.4 ± 1.0 vs 1.4 ± 1.1, respectively; p = 0.623) and differed for the RAS vs open groups (1.4 ± 1.0 vs 2.0 ± 1.9, respectively; p < 0.001). Conversion rates differed between RAS and laparoscopic groups (0.6% vs 4.9%; p = 0.004). The number of subjects reporting the need to take prescription pain medication through the 2-4 weeks visit differed between RAS vs open (65.2% vs 79.8%; p < 0.001) and RAS vs laparoscopic (65.2% vs 78.75%; p < 0.001). For those taking prescription pain medication, the mean number of pills taken was comparable for RAS vs open (23.3 vs 20.4; p = 0.079) and RAS vs laparoscopic (23.3 vs 23.3; p = 0.786). Times to return to normal activities and to work, complication rates and HerQLes QOL scores were comparable for the RAS vs open and RAS vs laparoscopic groups. The reoperation rate within 30 days post-procedure was comparable for RAS vs laparoscopic (0.6% vs 0%; p = 0.296) and differed for RAS vs open (0.6% vs 3.1%; p = 0.038).

CONCLUSIONS

Short-term outcomes indicate that open, laparoscopic, and robotic-assisted approaches are effective surgical approaches to VIH repair; however, each repair technique may demonstrate advantages in terms of clinical outcomes. Observed differences in the RAS vs laparoscopic comparison are longer operative time and lower conversion rate in the RAS group. Observed differences in the RAS vs open comparison are shorter LOS and lower reoperation rate through 30 days in the RAS group. The operative time in the RAS vs open comparison is similar. The number of subjects requiring the use of prescription pain medication favored the RAS group in both comparisons; however, among subjects reporting a need for pain medication, there was no difference in the number of prescription pain medication pills taken. While the study adds to the body of evidence evaluating the open, laparoscopic, and RAS approaches, future controlled studies are needed to better understand pain and QOL outcomes related to incisional hernia repair.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02715622.

A cost analysis of two- versus three-instrument robotic-assisted inguinal hernia repair with mesh: time is money

Equipment expenses and operating times can lead to higher costs with robotic surgery. We compared the cost-effectiveness of 2- vs. 3-instrument (2i vs. 3i) approach to robotic transabdominal preperitoneal inguinal hernia repair. We conducted a retrospective study of 172 patients, with 86 patients in each group. Procedure cost, operative time, morbidity, length of stay, readmission rate, and hernia recurrence at 90 days were compared. Statistical significance was assigned to p < 0.05. No significant differences in preoperative variables nor in postoperative outcomes were identified. Mean operative time was 6 min longer in the 2i group and this approach cost $300 less. The 2i approach was cost-effective for operating room (OR) costs of less than $50 per minute. Surgeon efficiency and OR dollar-per-minute value influence the potential for cost savings with fewer instruments in robotic herniorrhaphy. There is no difference in outcomes when fewer instruments are used.

Ventral Hernia Management in Obese Patients

Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.

Técnica extraperitoneal comparada con IPOM plus: Análisis de costos evitados para optimizar el manejo de la hernia ventral por laparoscopia

Introducción. Analizamos los costos en el reparo extraperitoneal de la hernia ventral por laparoscopia, desde la perspectiva del sistema general de salud de Colombia, con el fin de mostrar los beneficios de dicho abordaje y su impacto económico, al compararlo con la técnica más implementada, el IPOM plus. Métodos. Se realizó un análisis económico de costo-beneficio, desde la perspectiva del Sistema General de Seguridad Social en Salud (SGSSS) de Colombia, comparando los costos del reparo de hernia ventral con la técnica extraperitoneal, TAPP o TEP, versus el IPOM plus. Se tomaron como costos de referencia lo establecido en el manual tarifario de Instituto de Seguros Sociales. Los datos fueron analizados con Stata V.15    Resultados. Se recolectó y analizo información de 109 procedimientos; 59 del grupo extraperitoneal TAPP/TEP y 50 del grupo IPOM plus, realizados durante los años 2015 a 2018, por el grupo de pared abdominal de Clínica Colsanitas, identificando un ahorro del 69,8 % o resultados de costo-beneficio a favor del grupo extraperitoneal. Discusión. El abordaje extraperitoneal en el reparo de hernia ventral se consideró una estrategia de alto costo-beneficio para el sistema de salud, validado por la experiencia del grupo de pared abdominal de Clínica Colsanitas, al compararla con el abordaje habitual. Teniendo en cuenta que los insumos utilizados para la disección no cambian, la prótesis utilizada para cada una de las técnicas representa un costo importante a considerar, tanto para el sistema como para las instituciones de salud

Short-term quality of life comparison of laparoscopic, open, and robotic incisional hernia repairs

BACKGROUND

Outcomes of incisional hernia repair (IHR) include recurrence and quality of life (QOL). Operative approaches include laparoscopic, open, and robotic approaches. Data regarding comparative QOL outcomes among these repair types are unknown. Our study evaluates quality of life after three approaches to IHR.

STUDY DESIGN

Patients undergoing open (OHR), laparoscopic (LIHR), and robotic extra-peritoneal (RIHR) at a single institution from 2009 to 2019 were reviewed from a prospectively managed quality database. Short-term QOL was compared among the three procedures using the Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CCS), objective pain scores and postoperative narcotic use. Data regarding length of stay (LOS), emergency department (ED) visits, readmission, reoperations and surgical site infection (SSI) were also collected.

RESULTS

A total of 795 patients undergoing IHR were analyzed (418 open, 300 laparoscopic and 77 robotic). Patient were similar in age, gender and co-morbidities. LIHR patients had higher BMI and RIHR patients had larger hernia and mesh size. LOS was longer and rate of SSI was higher for OIHR compared to laparoscopic and RIHR. Patients undergoing LIHR reported increased narcotic use, Visual Analogue Scale (VAS) and CCS pain scores compared to open and robotic repair. Return to daily activity was 4 days shorter for robotic than open and laparoscopic repair; ED visits, readmissions, reoperations, and other QOL domains were similar.

CONCLUSION

Our data suggests that short-term quality of life after robotic extra-peritoneal IHR is improved compared to open and laparoscopic repair. Additional follow up is required to determine differences in long-term QOL after IHR.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Totally Endoscopic Sublay Anterior Repair for Ventral and Incisional Hernias

BACKGROUND

Endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. To combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose Totally Endoscopic Sublay Anterior Repair (TESAR) a safe and feasible approach for the treatment of ventral and incisional midline hernias.

METHODS

From May to November 2018, 12 patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for TESAR. Exclusion criteria were: complicated ventral or incisional hernia (i.e., incarcerated hernia), maximum defect width >7 cm, and contraindications to general anesthesia.

RESULTS

All procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. No intraoperative complications were registered. Total mean operative time was 148 ± 18.5 minutes. No postoperative major complications were registered. Only one subcutaneous seroma was registered (8.3%) and treated conservatively. The mean postoperative stay was 2.6 ± 0.6 days.

CONCLUSIONS

TESAR is a safe and feasible technique for the extraperitoneal sublay repair of ventral hernias with a totally endoscopic approach. It provides accurate hernia repair with good outcomes in terms of resolution of symptoms and postoperative complications.