Systematic review of robotic ventral hernia repair with meta-analysis

A Retrospective Study Comparing the Operative Outcomes of Extraperitoneal, Retrorectus Access Laparoscopic and Robotic-Assisted Ventral Hernia Repairs

BACKGROUND

This retrospective study aims to evaluate the operative outcomes of laparoscopic and robotic extraperitoneal repair of abdominal wall defects via enhanced view total extraperitoneal (eTEP) retrorectus space access.

METHODS

A medical chart review was performed on consecutive eTEP cases from our unit, focused on collecting perioperative outcomes.

RESULTS

One hundred and twenty cases were collected, 73 in the robotic group and 47 in the laparoscopic group. Approximately 38% of the robotic and 64% of the laparoscopic arms required component separation. In the overall population (irrespective of defect size and technique used), the robotic arm versus the laparoscopic arm had (a) significantly higher (P < 0.001) mean hernia defect, (b) shorter operating time (P < 0.001), (c) significantly fewer postoperative complications (P = 0.039), (d) significantly fewer pain scores at 24 hours and 14 days postsurgery (P = 0.002 and P < 0.001, respectively), and (e) better patient well-being scores (P = 0.001). The length of hospital stay and analgesic usage were comparable. A subgroup analysis by defect size (< 7 cm, 7-10 cm, and > 10 cm) revealed that approximately 51% of patients needed component separation in the laparoscopic group for defects < 7 cm, and 100% of patients needed it for hernias > 7 cm in this group. In the robotic group, no patient (0%) needed component separation for defects < 7 cm, and approximately 43% needed it for defects > 7 cm.

CONCLUSIONS

This study reports encouraging short-term outcomes for the robotic-assisted eTEP approach in Indian settings. The robotic-assisted approach has the potential to reduce the requirement of component separation in patients with large ventral hernia defects. However, future prospective, randomized studies with long-term follow-up on recurrence will be needed to validate our findings.

Minimally invasive approach in emergency for the treatment of acute incarcerated/strangulated ventral hernias. A systematic review and meta-analysis

BACKGROUND

This study aims to report the currently available evidence on minimally invasive surgery (MIS) in emergency settings for treating acute incarcerated/strangulated ventral, primary, or incisional hernias and compare it with the open approach.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

RESULTS

Six articles were included. Results of the meta-analysis based on 1720 patients and two articles show that the mean operative time was shorter in the open repair group compared to the MIS group (mean difference [MD], 39.53 min; p < 0.0002). Overall, 116 (13.6%) and 181 (20.9%) postoperative complications were observed after MIS and open repair, respectively (relative risk [RR], 0.65; p = 0.61). MIS was associated with a statistically significantly lower wound complication rate than the open approach (RR, 0.43; p = 0.50). The two approaches showed equivalent results regarding return to the operative room (RR, 0.61; p = 0.13). The mean hospital stay in the MIS group was shorter than the open group (MD, -0.68; p = 0.99).

CONCLUSIONS

MIS in emergency settings seems feasible for treating acute incarcerated ventral hernias. However, due to the limitations of the included studies, the obtained evidence should be analyzed with caution. Further prospective studies are required to draw definitive conclusions.

HUGO™ system robotic eTEP technique for ventral hernia repair. A step-by-step medial bottom-up approach

This study describes an innovative robotic extended totally extraperitoneal (eTEP) technique for ventral hernia repair via a medial bottom-up approach using the new HUGO™ system. The surgical steps and a novel setup guide for this approach are detailed. A 78-year-old male with an incisional umbilical hernia and concomitant rectus diastasis was treated using the HUGO™ system. The system's modular design enabled a customized surgical approach. Robotic eTEP repair was performed via a medial bottom-up approach, and robotic trocars were placed in the hypogastric region. Single docking was sufficient. The procedure lasted 180 min, with no intraoperative complications. The patient's postoperative recovery was uneventful, and a normal diet was resumed on the first postoperative day. The postoperative hospital stay was 7 days. Satisfactory outcomes without complications were observed during follow-up. This study introduced a novel robotic eTEP approach for abdominal wall hernia repair using the HUGO™ system, highlighting the medial bottom-up technique and an innovative docking configuration. The medial bottom-up robotic eTEP approach using the HUGO™ system is a feasible and promising technique for abdominal wall hernia repair. To evaluate long-term outcomes and broader applicability among surgeons experienced in robotic and retromuscular hernia repair, further studies are warranted.

Systematic review and meta-analysis on robotic assisted ventral hernia repair: the ROVER review

INTRODUCTION

Robotic surgery for ventral hernia repair (VHR) is gaining attention for its potential advantages over laparoscopic and open techniques. This approach combines the advantages of minimally invasive surgery with the ability to perform technically challenging procedures, often required in open surgery but difficult with conventional laparoscopy. We aim to evaluate the efficacy and safety of robotic VHR compared to other surgical approaches, focusing on postoperative complications, operative time, and costs.

MATERIAL AND METHODS

A systematic review with meta-analysis were conducted, including 67 studies from January 2010 to May 2023 on Robotic VHR compared with other techniques. Primary outcome was 30-days postoperative complications; SSI, SSO, seroma, mortality, recurrence, length of hospital stay, operative time and costs were analysed as secondary outcomes.

RESULTS

Robotic surgery was associated with longer operative times compared to both laparoscopic (MD 64.67 min; p < 0.001) and open repairs (MD 69.69 min; p < 0.001). However, it resulted, compared to open surgery, in fewer SSIs (OR 0.62; p 0.05), mortality (OR 0.44; p 0.04) and shorter hospital stay (MD -3.77 days; p < 0.001). No differences were found in overall complications or length of stay between robotic and laparoscopic approaches but higher costs and longer operative times were reported in robotic VHR.

CONCLUSIONS

Based on the currently available low-quality evidence, robotic VHR appears to offer limited advantages compared to laparoscopic techniques. However, when compared to open approaches, robotic VHR may demonstrate reduced postoperative complications and shorter hospital stays even if an higher rate of seroma formation was retrieved probably related to technical details. Nevertheless, longer operative times and higher costs remain significant limitations. Further high-quality comparative studies are warranted to assess long-term outcomes and cost-effectiveness.

Outcomes from 306 consecutive robotic ventral hernia repairs in the community setting

Robotic assisted laparoscopy is increasingly popular for primary ventral and incisional hernia repair. A variety of robotic techniques have been described. More data is needed to evaluate the indications and benefits of these approaches. This is a retrospective analysis of patients who underwent robotic hernia repair over a 2-year period in the community setting. Techniques included: intraperitoneal onlay mesh repair with fascial defect closure (IPOM +), ventral transabdominal preperitoneal repair (vTAPP), and retrorectus (RR) repairs with or without transverse abdominis release (TAR). Follow up was obtained at minimum 6 months postoperatively. Outcomes data included complications, readmissions, reoperations, and hernia recurrences. This study included 306 consecutive robotic ventral hernia repairs: 63 IPOM + , 199 vTAPP, and 44 RR of which 25 (57%) required TAR. Average console times were similar between IPOM + and vTAPP groups (63 vs. 62 min, p = 0.71) and longer for RR repairs without vs. with TAR (107.8 vs. 184.4 min, p < 0.001). There were few intraoperative (0.6%) and immediate postoperative (0.3%) complications. Same day discharge was feasible in most patients (95%). Follow up was completed in 81.0% of patients with an average follow up time of 13.3 months (range 6-27 months). Rates of complications (1.3%), readmissions (1.0%), and reoperations (1.0%) were recorded. There were no hernia recurrences. Robotic ventral hernia repair is a safe and effective strategy for treatment of most abdominal wall hernias with low complication and recurrence rates in medium term follow up.

Open versus robotic transversus abdominis release for ventral hernia repair: an updated systematic review, meta-analysis, and meta-regression

AIM

Posterior component separation using transversus abdominis release (TAR) is well established as an option for repair of large hernia defects. TAR can be performed robotically (rTAR) or open (oTAR) with limited data to demonstrate benefit and guide decision making. We conducted a systematic review and meta-analysis comparing rTAR and oTAR approaches for ventral hernia repair (VHR).

MATERIAL AND METHODS

We searched Pubmed, Embase, Cochrane, and Web of Science for studies comparing rTAR and oTAR for VHR. Hybrid rTAR was not included in our analysis. Our primary outcomes were overall postoperative and intraoperative complications, surgical site occurrences (SSO), SSO requiring surgical intervention (SSOPI), surgical site infection (SSI) superficial or deep, and fascial closure. Additional outcomes were operative time (OT), readmission, length of hospital stay (LOS). We performed sensitivity analysis to explore reasons for heterogeneity and outliers, and a proportional meta-analysis of conversion during rTAR. We performed a meta-regression exploring the relationship of BMI, hernia defect and mesh width rTAR/oTAR with the analyzed outcome within each study.

RESULTS

503 studies were screened and seven studies were included in this analysis. Our sample totaled 780 patients, of which 298 (38.2%) underwent rTAR. Defect width ranged between 8.7 to 13.5 cm (cm) for rTAR and 10 to 13.5 cm for oTAR. Mean mesh area ranged from 66.9 to 980 cm2 and from 51.3 to 1344 cm2 for rTAR and oTAR respectively. We found lower overall complications (9% versus 24.6%; RR 0.43; 95% CI 0.26 to 0.73; P < 0.01) and intraoperative complication (5.9% versus 9.1%; RR 0.44; 95% CI 0.22 to 0.88; P = 0.02) rates for the rTAR group. There was no difference in fascial closure between the groups (99% versus 94.6%; RR 1.05; 95% CI 0.99 to 1.11; P = 0.11). rTAR presented lower SSI rates (2.5% versus 7.8%; RR 0.33; 95% CI 0.13 to 0.8; P = 0.01). No differences were found in SSO (16.3% versus 13.7%; RR 0.87; 95% CI 0.51 to 1.48; P = 0.6) or SSOPI (5.4% versus 8.9%%; RR 0.5; 95% CI 0.22 to 1.15; P = 0.1) rates. No statistically significant differences were found in superficial SSI (0.76% versus 3%; RR 0.36; 95% CI 0.07 to 1.75; P = 0.21) and deep SSI (0% versus 4.2%; RR 0.23; 95% CI 0.02 to 3.12; P = 0.27). Open surgery presented a lower OT (MD -67.7 min; P < 0.001), but robotic surgery showed a reduced LOS (-3.9 days; 95% CI -4.8 to -3.1; P < 0.001). No differences were found in readmission and 1 year recurrence rates. The proportional meta-analysis showed a conversion to open rate of 6.4 per 100 patients (95% CI 3.3 to 12 patients) during rTAR. Meta-regression presented no statistically significant influences of rTAR/oTAR mesh width and defect width relations and BMI, despite the analysis was limited by the low number of studies.

CONCLUSION

Robotic TAR may be associated with lower intraoperative and postoperative complications, lower SSI, shorter LOS, and longer operative times when compared to oTAR. Given the limitations of the included studies, randomized trials are needed to better evaluate the impact of the robotic-assisted surgery for complex abdominal wall reconstruction.

PROSPERO REGISTRATION

CRD42024540991.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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