Robotic retromuscular abdominal wall repair using an inverted TEP (iTEP) approach: surgical technique and short-term outcomes

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.

Robotic trans-abdominal retromuscular hernia repair for medium-sized midline hernias: midterm outcomes and surgical site occurrence (SSO) analysis in 120 patients

Robotic surgery has become a popular method for treating ventral hernias due to its promising peri-operative outcomes. However, the long-term results of this approach are still unclear. In this study, 120 patients underwent robotic trans-abdominal retromuscular mesh placement (r-TARM) with a mean follow-up period of 18.1 months. This study aims to evaluate the feasibility of the robotic approach reporting peri-operative and midterm outcomes. Additionally, we examined possible risk factors that may contribute to the development of surgical site occurrences (SSOs). Between January 2021 and September 2023, 120 patients underwent r-TARM for midline hernias, including 39 primary, 71 incisional, and 10 recurrent cases. A retrospective analysis was performed. A logistic regression model was used to identify possible patient risk factors for SSO development. The average operative time was 153.5 ± 47.2 min, and there were no open or laparoscopic approach conversions. The mean length of hospital stay was 1.9 ± 0.9 days. We observed SSO in 16 patients (13.3%). One patient (0.8%) required angiographic embolization due to post-operative parietal bleeding. The mean follow-up time was 18.1 ± 7.8 months, and we observed hernia recurrence in only one (0.8%) patient. The logistic regression model did not identify any possible risk factors for SSO. r-TARM is a safe and effective method for treating ventral hernias not requiring posterior component separation. Our results indicate that patient and hernia characteristics were not predictive of SSO. Midterm outcomes are encouraging, though longer follow-up is needed.

Robotic preperitoneal extended totally extraperitoneal (R-PeTEP) technique description for ventral hernia repair: preliminary results

PURPOSE

Transabdominal preperitoneal (TAPP) ventral hernia repair requires incising the peritoneum from within the abdominal cavity, developing a flap, and placing a reinforcing mesh after fascial closure from the preperitoneal space. We present a novel adaptation to this technique that allows placement of preperitoneal mesh without entering the abdominal cavity. The robotic totally extra- and preperitoneal (R-PeTEP) access for ventral hernia repair is best suited for small to moderate sized ventral hernias with concomitant diastasis recti.

METHODS

Our study is a retrospective review of all patients who underwent R-PeTEP from December 2022 to November 2023. A comprehensive description of the surgical technique is included. Patient demographics, hernia characteristics, as well as clinical outcomes are described.

RESULTS

A total of 25 patients underwent R-PeTEP for ventral hernia repair with diastasis recti plication. The median age was 55 years (IQR 43.5-63) and 92% (n = 23) were male. The median ASA score was 2 (IQR 1-2) and the median BMI was 30.4 (IQR 29.3-32.8) with 64% (n = 16) percent having a BMI ≥ 30. Median hernia width was 3 cm (IQR 3-4), with a median diastasis recti width of 4 cm (IQR 2.6-4) and length of 15 cm (IQR 11.8-16). The median operative time was 120 min (IQR 116-134). All repairs were reinforced with permanent mesh. Sixty-eight percent of the patients (n = 17) were discharged on the same day. With a median follow-up of 30 days (IQR 16-107), 8% (n = 2) seromas, 16% (n = 4) developed clinically insignificant hematomas, and one patient (4%) developed ileus that was managed conservatively.

CONCLUSION

This study establishes the feasibility and safety of R-PeTEP, which provides direct access to the preperitoneal space, avoiding disruption to the posterior rectus sheath, possibly reducing neurovascular bundle injuries, and omitting entry to the abdominal cavity. R-PeTEP facilitates wide flap creation for prosthetic overlap and allows for posterior plication of diastasis recti with little to no mesh fixation with overall excellent preliminary clinical outcomes.

Strategies for closing the posterior rectus sheath during enhanced view totally extraperitoneal Rives-Stoppa repair

INTRODUCTION

The popularity of endolaparoscopic extraperitoneal repairs has been on the rise due to advantages such as sublay mesh placement and early return to daily activities. However, the procedure requires overcoming a learning curve, and with increased adoption, new complications have emerged. One significant complication is the rupture of the posterior rectus sheath (PRS). In this article, we present our modifications of the technique to reduce tension during PRS closure.

PATIENTS AND METHODS

The study included 105 patients who underwent endolaparoscopic extraperitoneal repairs for ventral hernias using two different techniques. Group A ( n = 68) underwent the original technique, whereas Group B ( n = 37) underwent the modified technique. The modifications in Group B included preserving the peritoneal bridge between the two PRS and the hernia sac, conducting a complete dissection of the space of Bogros and adopting a transverse or oblique closure of PRS along the lines of least tension. To assess the efficacy of these modifications in preventing PRS rupture, we compared the results of both groups.

RESULTS

Our findings indicate that following all the technical steps of the modified technique resulted in a reduced need for transversus abdominis release for PRS closure and a lower incidence of PRS rupture in the postoperative period. However, to further validate the effectiveness of these modifications, a larger follow-up period and a bigger sample size are required.

CONCLUSIONS

The adoption of the modified technique can help achieve a tension-free PRS closure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Switching from robotic-assisted extended transabdominal preperitoneal (eTAPP) to totally extraperitoneal (eTEP) hernia repair for umbilical and epigastric hernias

Our study aimed to assess the safety and effectiveness of the robotic-assisted extended totally extraperitoneal (eTEP) repair compared to transabdominal preperitoneal (eTAPP) repair with a suprapubic trocar insertion to treat umbilical and epigastric hernias. On a prospectively maintained database, we identified patients who underwent either eTEP or eTAPP for treating umbilical and epigastric hernias. During the study period, 53 patients were included, 32 in the eTEP group and 21 in the eTAPP group. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male, and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). The operative time for eTEP was slightly shorter than for eTAPP (106 ± 43 min vs. 126 ± 74 min, p = 0.232). Postoperatively, only one case of bleeding and one seroma were recorded. No complication occurred during a mean follow-up of 11.3 ± 6.4 months in the eTEP group and 20.5 ± 9.7 months in the eTAPP group. In conclusion, our study showed that the eTEP with suprapubic approach was safe and feasible in the treatment of epigastric and umbilical hernias. According to our experience, shorter operative time, integrity of the posterior layers and increased overlap size are the main surgical reasons of switching from eTAPP to eTEP.

Minimally Invasive Extended Totally Extraperitoneal Versus Transabdominal Retromuscular Ventral Hernia Mesh Repair: Systematic Review and Meta-Analysis

Introduction: Minimally invasive surgery for ventral hernia repair (MIS-VHR) with mesh in retromuscular plane can be performed by either transabdominally (TA-RM) or via enhanced view totally extraperitoneal approach (eTEP). Although both techniques offer the mesh extension in the best anatomical space, closure of hernia defect, avoidance of traumatic fixation, the superiority of one approach over another is not established. This systematic review and meta-analysis were set up to analyze safety and efficacy of eTEP in comparison with TA-RM. Materials and Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework was used as guideline to conduct systematic search of literature. Studies that provided comparative data of MIS-VHR using eTEP versus TA-RM were identified. Primary outcomes were major complications. These were defined as grade III-IV according to Clavien-Dindo classification. Secondary outcomes included: surgical site infection (SSI) rates, seroma rates, surgical site occurrence requiring procedural intervention (SSOPI), minor complications (Clavien-Dindo grade I-II), intraoperative complications, recurrence rate, postoperative ileus, duration of surgery, postoperative pain. Random- and fixed-effects models of statistical analysis were used. Risk difference (RD) was computated for binary outcomes (major and minor complications, SSI, seroma, SSOPI, recurrence, ileus) with 95% confidence intervals. I2 test was used to assess statistical heterogeneity. Risk of bias assessment was performed using Newcastle-Ottawa framework. Results: There were 3 observational studies that enrolled 370 participants. In the eTEP group there were 166 patients and, in the TA-RM group there were 204 patients. There was no significant RD with regard to major complications (RD -0.02 [-0.06 to 0.02], test for overall effect: Z = 0.86 [P = .39]). There was no significant RD in occurrence of minor complications, SSI, seroma, SSOPI, recurrence, ileus. Conclusions: Both eTEP and TA-RM were found to have equal safety profile. Further high-quality studies evaluating patient reported outcomes and late recurrence may be useful. PROSPERO registration number: CRD42023429160.