Comparative analysis of perioperative outcomes of robotic versus open transversus abdominis release

Robotic hernia repair with the novel HUGO robot system - An initial experience from a tertiary centre

BACKGROUND

Hernia repair using robotic platforms has been on the rise in the last decade. The HUGO robotic-assisted surgery (RAS) system, introduced in 2021, is a new addition to the field. In this study, we share our experience with this innovative system for the management of ventral and groin hernias.

PATIENTS AND METHODS

The aim of our study was to evaluate the feasibility and safety of using the HUGO robotic platform for hernia surgeries. We conducted a retrospective analysis of all hernia surgeries performed with the HUGO system over a 1-year study period. The study assessed various aspects, including the technical manoeuvres of the robotic system, duration of surgery, length of hospital stay, post-operative pain levels and 30-day morbidity rates.

RESULTS AND CONCLUSIONS

A total of seven hernia surgeries were performed using the HUGO system, including five ventral hernias and two groin hernias. The average duration of surgery was 128 min, with a docking duration of 22.8 min. Notably, there were no intraoperative or post-operative adverse events reported during these procedures. The HUGO system features an open console that provides a panoramic view of the operating room. In addition, the individual arm carts can be easily manoeuvred around the operating table, facilitating improved access to multiple quadrants during surgery. In our case series, Robotic hernia repair using the HUGO system has demonstrated feasibility, with post-operative outcomes comparable to traditional approaches. This innovative system serves as an additional tool in the armamentarium of hernia surgery and shows potential for improving surgical outcomes. However, further investigation through large-scale prospective studies is necessary to comprehensively evaluate its efficacy and benefits.

Robotic parastomal hernia repair: an updated systematic review

INTRODUCTION

Parastomal hernias (PSH) are a frequent complication following ostomy surgery, often requiring surgical intervention. Robotic surgery offers potential advantages in PSH repair, but evidence on its efficacy remains limited. This systematic review evaluates the outcomes of different robotic PSH repair techniques.

EVIDENCE ACQUISITION

A systematic search of PubMed, Embase, and Cochrane databases was conducted (2015-2024) to identify studies on robotic PSH repair. Fourteen studies (13 retrospective, two prospective) met the inclusion criteria after screening 324 articles.

EVIDENCE SYNTHESIS

Data on patient demographics, surgical techniques, complications, recurrence rates, and follow-up duration were extracted. The analysis included 355 patients with a median follow-up of 12 months. Early studies focused on feasibility and safety, with subsequent research refining specific techniques like the Sugarbaker, Pauli, and keyhole repairs. Reported recurrence rates ranged from 0% to 9.5% across these techniques. However, 30-day complication rates varied significantly (0% to 50%), highlighting the need for standardized reporting and patient selection criteria. While some studies demonstrated low recurrence rates with acceptable complication profiles, others revealed higher complication rates, potentially related to specific techniques or patient factors. The emergence of variations within the Sugarbaker technique, such as the retromuscular approach with transversus abdominis release (TAR), demonstrates ongoing innovation in robotic PSH repair.

CONCLUSIONS

Robotic PSH repair shows promise, but further research is needed to confirm its long-term efficacy and cost-effectiveness.

Laparoscopic Versus Robotic Ventral Hernia Repair - An ACHQC Database 5-Year Analysis

Introduction

To compare laparoscopic and ventral hernia repair (VHR) in the last 5 years in the United States utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database.

Materials and Methods

A retrospective review of prospectively collected data from the ACHQC database was performed to include all adult patients that underwent laparoscopic and robotic VHR in the last 5 years. Univariate analysis was performed to compare outcomes from laparoscopic and robotic-assisted approaches across perioperative and postoperative outcomes.

Results

ACHQC database identified 11,096 patients with midline hernias who underwent VHR with mesh. The Laparoscopic group with patients from 2018 to 2023 (LAP) had 2,063 patients, and the robotic group (ROBO) had 9,033 patients. There was no difference in sex, age, BMI, DM, smoking status and COPD between groups. Median hernia width was 4 cm (IQR 2-6) in the ROBO group and 3 cm (IQR 2-5) in the LAP group (p < 0.001). Incisional hernia was higher in the ROBO group 5,259 (58%) versus 1,099 (53%) in the LAP group (p < 0.001). Recurrent hernia was more common in the ROBO group when compared with the LAP group (p < 0.001). Both groups had more permanent synthetic mesh. Retromuscular repair was higher in the ROBO group, 3,201 (37.6%) versus 68 (4.2%) in the LAP group (p < 0.001). The intraperitoneal repair was higher in the LAP group 1,363 (83%) versus 2,925 (34%) in the ROBO group (p < 0.001) Transversus Abdominis Release (TAR) was higher in the ROBO group 1,314 (14.5%) versus 5 (0.2%) in the LAP group (p < 0.001). Fascial closure was higher in the ROBO group (8,649; 96.5% versus 1,359; 67.3% in the LAP group p < 0.001). Regarding mesh fixation, regular suture was higher in the ROBO group 92% versus 61% in the LAP group (p < 0.001). Tacks (p < 0.001) was higher in the LAP group. The ROBO group had more patients with an operative time of 240+ minutes when compared with the LAP group (p < 0.001). There was no difference in 30-days readmission rates, recurrence, reoperation, overall postoperative complications, 30-day SSI, SSO, seroma and SSOPI between the groups.

Conclusion

The Robotic approach was associated with more technically challenging ventral hernia repairs with low complication rates over time. However, no differences in postoperative complications were found between the groups.

Comparing Open and Robotic Unilateral Transversus Abdominis Release in Incisional Hernias With a Lateral Component: A Single Center Retrospective Study

Introduction

Lateral hernias are often more challenging to correct when compared to midline defects, due to the anatomic boundaries of the bony pelvis, retroperitoneum, and costal margin. With the insurgence of robot assisted abdominal wall surgery, these defects have been found more manageable through a minimal invasive repair. In this study, we aim to present our short-term results of incisional hernia repair with a lateral component requiring a unilateral transversus abdominis release, through open surgery versus robot assisted.

Methods

A retrospective analysis was performed of our robotic and open abdominal wall repairs of lateral hernias, where a unilateral transversus abdominis release was performed, between January 2017 and December 2023. Patient, hernia and perioperative details are reported.

Results

54 patients in the open group versus 10 patients in the robotic group were included. Hernia width and hernia surface area were higher in the open group, but not significant. Operation time was similar between open and robotic procedures. In-hospital complications, surgical site infection and clinical seroma rate during the first 30 postoperative days were similar in both groups. There was a clear difference in length of stay, in favor of the robotic group.

Discussion

In our limited series, a robotic approach seems safe and feasible when faced with large lateral hernias. Short-term results show a shorter length of stay using the robotic approach, with no significant difference in short term complications, specifically SSI-rate. However, conclusions are limited due to the low number of patients and additional studies should be performed to account for long term recurrence and increase included patient number.

Single-dock Robotic Bilateral Transversus Abdominis Release: Technique Description and Preliminary Outcomes

BACKGROUND

Posterior component separation with transversus abdominis release (TAR) is a valuable adjunct to address incisional hernia defects. Currently, bilateral docking is a standard technique for robotic TAR. The aim of this study is to describe our technique for extended totally extraperitoneal (eTEP) repair with bilateral TAR through a bottom single-dock robotic approach for hernias at the level of the umbilicus or higher.

MATERIALS AND METHODS

We retrospectively reviewed a case series of patients who underwent robotic eTEP repair with bilateral TAR using a single bottom docking between November 2021 and November 2023. A comprehensive description of our patient selection, surgical technique, and short-term clinical outcomes is reported.

RESULTS

Ten patients with incisional hernias were included. Their median age was 55 years (IQR: 49.5 to 61.25), 70% were male, the median BMI was 27.25 kg/m (IQR: 22.95 to 33.53), and ASA class was ≥2 in 80%. Median hernia width was 10 cm (IQR: 6.75 to 12.25) and length 11 cm (IQR: 9.25 to 16.25). The median operative time was 178.5 minutes (IQR: 153.75 to 222), and the length of stay was 1 day (IQR: 0.75 to 1.75). At a median follow-up of 5 months (IQR: 2.6 to 9.7), 20% of patients developed a surgical site occurrence requiring procedural intervention.

CONCLUSION

Bilateral TAR using a single bottom dock is a feasible and safe adjunct to robotic eTEP ventral hernia repair in appropriately selected patients.

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.

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.

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.

Computed tomography measurements to predict need for robotic transversus abdominis release: a single institution analysis

PURPOSE

The radiographic rectus width to hernia width ratio (RDR) has been shown to predict ability to close fascial defect without additional myofascial release in open Rives-Stoppa abdominal wall reconstruction (AWR), but it has not been studied in robotic AWR. We aimed to examine various CT measurements to determine their usability in predicting the need for transversus abdominis release (TAR) in robotic AWR.

METHODS

We performed a single-center retrospective review of 137 patients with midline ventral hernias over a 5-year period who underwent elective robotic retrorectus AWR. We excluded patients with M1 or M5 hernias, lateral/flank hernias, and hybrid repairs. The CT measurements included hernia width (HW), hernia width/abdominal width ratio (HW/AW), and RDR. Univariate, multivariate and area under the curve (AUC) analyses were performed.

RESULTS

58/137 patients required TAR (32 unilateral, 26 bilateral). Patients undergoing TAR had a significantly higher average HW and HW/AW and lower RDR. Multivariate analysis revealed that prior hernia repair was independently associated with need for TAR (p = 0.03). ROC analysis and AUC values showed acceptable diagnostic ability of HW, HW/AW and RDR in predicting need for TAR. Cutoffs of RDR ≤ 2, HW/AW > 0.3, and HW > 10 cm yielded high specificity in determining need for any TAR (97.5% vs. 96.2% vs. 92.4%) or bilateral TAR (95.5% vs. 94.6% vs. 92.8%).

CONCLUSION

History of prior hernia repair was a risk factor for robotic TAR. CT measurements have some predictive value in determining need for TAR in robotic AWR. Further prospective analysis is needed in this patient population.

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.

Short-Term Outcomes of Transabdominal Preperitoneal Ventral Hernia Repair With Rectus Aponeuroplasty (TAPPRA) for the Management of Incisional Hernias

Introduction

Options for minimally invasive ventral hernia repair continue to evolve as a function of our understanding of the abdominal wall and the development of new techniques. We describe a robotic transabdominal pre-peritoneal repair with concurrent rectus aponeuroplasty (TAPPRA) for incisional and recurrent ventral hernias.

Methods

All patients in this retrospective cohort study underwent TAPPRA repair between October 2023 and March 2024. This study aimed to determine intraoperative feasibility of the technique and to assess immediate postoperative outcomes.

Results

Twelve patients underwent TAPPRA repair for incisional and/or recurrent ventral hernias at an academic hernia center. The median case duration was 135 min with no significant intraoperative complications noted. Average defect size for the hernias measures 6.5 × 8.5 cm. Polypropylene mesh was used to reinforce all defects, with the average dimensions being 19.7 × 21.5 cm. 83% of patients were discharged within 24 h of their procedure. No significant postoperative complications were noted.

Conclusion

We describe the first use of a novel ventral hernia repair technique, TAPPRA, and demonstrate that it is safe, feasible, and associated with appropriate short-term outcomes for repair of moderate sized incisional hernias.

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.

Outcomes of Transversus Abdominis Release With Macroporous Polypropylene Mesh

INTRODUCTION

Transversus abdominis release (TAR) is increasingly being performed for reconstruction of complex incisional and recurrent ventral hernias, with complication rates ranging from 17.4% to 33.3% after open TAR (oTAR) or robotic TAR (rTAR). The purpose of this study was to describe the outcomes of patients undergoing TAR with macroporous polypropylene mesh (MPM) and to compare outcomes between oTAR and rTAR.

METHODS

A retrospective review of 183 consecutive patients undergoing TAR with MPM performed by a single surgeon at a single institution from 2015 to 2021 was performed. Patients with less than one year of follow-up were excluded. Univariate analysis was performed to compare outcomes between oTAR and rTAR patients.

RESULTS

Average patient age was 59.4 y, median body mass index was 33.2 kg/m2, and median hernia width was 12.0 cm. Forty 2 (23%) patients underwent oTAR, 127 (69%) underwent rTAR, and 14 (8%) underwent laparoscopic TAR. Patients experienced 16.4%, 10.4%, 3.8%, and 6.0% rates of overall complications, surgical site occurrences, surgical site infections, and other complications, respectively. At average follow-up of 2.3 y, a 2.7% hernia recurrence rate was observed. In comparison to patients undergoing oTAR, rTAR patients required shorter operative times and length of stay, and were less likely to experience postoperative complications overall, and other complications. Recurrence rates were similar between oTAR and rTAR.

CONCLUSIONS

Patients undergoing TAR with MPM experienced complication and recurrence rates in alignment with previously published results. In comparison to oTAR, rTAR was associated with more favorable perioperative outcomes and complication rates, but similar recurrence rates.

Outcomes of Robotic Transabdominal Retromuscular Repair: 3-Year Follow-up

Background

Our study addresses the gap in ventral hernia repair literature, regarding the long-term effectiveness of robotic transabdominal retrorectus umbilical prosthetic repair (r-TARUP) for primary and incisional ventral hernias. This study aimed to report the 3-year recurrence rates and overall patient outcomes including quality of life.

Method

A retrospective review of prospective collected data analyzed 101 elective r-TARUP patients from August 2018 to January 2022. Data collected included demographics, hernia sizes, mesh types, postoperative outcomes and the European Hernia Society Quality of Life questionnaire (EuraHS-QoL) before and after surgery.

Results

The average age of the group of patients was 53, having a mean body mass index (BMI) of 32 kg/m, with 54% incisional and 46% primary hernias, with mean length and width of 4.4 cm and 6.1 cm, utilizing synthetic 58% and bioabsorbable 42% mesh types. The majority were classified as Centers of Disease Control and Prevention (CDC) class I wounds. Postoperative complications included seroma (2%), hematoma (3%), which required surgical intervention, with no significant correlation to mesh type. A strong positive correlation was found between Transversus Abdominis Release (TAR) and increased length of hospital stay (correlation coefficient: 0.731, p < 0.001). Preoperative quality of life assessments demonstrated statistically significant improvements when compared to postoperative assessments at 3 years, with a mean (±SD) of 61.61 ± 5.29 vs. 13.84 ± 2.6 (p < 0.001). Mean follow up of 34.4 months with no hernia recurrence at 1 year and 3 recurrence at the 2-3 years follow up (3.2%).

Conclusion

The r-TARUP technique has proven to be safe and effective for repairing primary and incisional ventral hernias, with a low recurrence rate during this follow up period with a noticeable improvement in quality of life (QoL).

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Robotic transversus abdominis release using HUGO RAS system: our initial experience

BACKGROUND

Transversus abdominis release (TAR) is an effective technique for treating large midline and off-midline hernias. Recent studies have demonstrated that robotic TAR (rTAR) is technically feasible and associated with improved outcomes compared to open surgery. There is no published experience to date describing abdominal wall reconstruction using the novel robotic platform HUGO RAS System (Medtronic®).

METHODS

All consecutive patients who underwent a rTAR in our institution were included. Three of the four arm carts of the HUGO RAS System were used at any given time. Each arm configuration was defined by our team in conjunction with Medtronic® personnel. rTAR was performed as previously described. Upon completion of the TAR on one side, a redocking process with different, mirrored arms angles was performed to continue with the contralateral TAR. Operative variables and early morbidity were recorded.

RESULTS

Ten patients were included in this study. The median BMI was 31 (21-40.6) kg/m2. The median height was 1.6 m (1.5-1.89 m). A trend of decreased operative time, console time, and redocking time was seen in these consecutive cases. No intraoperative events nor postoperative morbidity was reported. The median length of stay was 3 (1-6) days.

CONCLUSION

Robotic TAR utilizing the HUGO RAS system is a feasible and safe procedure. The adoption of this procedure on this novel platform for the treatment of complex abdominal wall hernias has been successful for our team.

Laparoscopic transversus abdominis release for complex ventral hernia repair: technique and initial findings

PURPOSE

The open Rives-Stoppa retrorectus and transversus abdominis release (TAR) techniques are well established in open ventral and incisional hernia repair. The principles are currently being translated into minimally invasive surgery with different concepts. In this study, we investigate our initial results of transperitoneal laparoscopic TAR for ventral incisional hernia repair (laparoscopic TAR).

METHODS

Over a 20-month period, 23 consecutive patients with incisional hernias underwent surgery. Laparoscopic TAR was performed transperitoneally with adhesiolysis from the anterior abdominal wall, development of the retrorectus space and TAR, midline reconstruction and extraperitoneal mesh reinforcement.

RESULTS

There were 23 incisional hernias, of which 70% were M2-M4 and 60% were W3. Median patient age was 68 years and the median BMI was 31. Median operating time was 313 min, and hospital stay was 4 days. Morbidity was 26% (Clavien-Dindo 1: n = 4 and 2 + 3b: n = 2).

CONCLUSION

With the laparoscopic TAR, it was possible to treat a series of patients with ventral incisional hernias. The operating times were long. However, with a low rate of perioperative complications the hospital stay was short As feasibility is demonstrated, the clinical relevance of the method has to be further evaluated.

Systematic review of robotic ventral hernia repair with meta-analysis

BACKGROUND

Despite being one of the most common operations performed by general surgeons, there is a lack of consensus regarding the recommended approach for ventral hernia repair (VHR). Recent times have seen the rapid development of new techniques, such as robotic ventral hernia repair (RVHR). This systematic review and meta-analysis aims to evaluate the currently available evidence relating to RVHR, in comparison to open VHR (OVHR) and laparoscopic VHR (LVHR).

METHODS

A systematic search of the following databases was conducted: PubMed, Embase, Scopus and Web of Science. A meta-analysis was performed for the outcomes of length of stay (LOS), recurrence, operative time, intraoperative complications, wound complications, 30-day readmission, 30-day reoperation, mortality and costs.

RESULTS

A total of 39 studies met inclusion criteria. Overall, RVHR reduced LOS, intra-operative complications, wound complications and readmission compared to OVHR. Compared to LVHR, RVHR was associated with increased operative time and costs, with comparable clinical outcomes.

CONCLUSION

There is currently a lack of robust evidence to support the robotic approach in VHR. It does not demonstrate major benefits in comparison to LVHR, which is more affordable and accessible. Strong quality, long-term data is required to help with establishing a gold standard approach in VHR.

Incisional hernia repair following pancreatic surgery-open vs laparoscopic approach

INTRODUCTION

For pancreatic procedures, transverse and midline or combined approaches are used. Having an increased morbidity after pancreatic surgery, these patients have an increased risk of developing an incisional hernia. In the following, we will analyze how the results of incisional hernia surgery after pancreatic surgery are presented in the Herniamed Registry.

METHODS

Hospitals and surgeons from Germany, Austria and Switzerland can voluntarily enter all routinely performed hernia operations prospectively into the Herniamed Registry. All patients sign a special informed consent declaration that they agree to the documentation of their treatment in the Herniamed Registry. Perioperative complications (intraoperative complications, postoperative complications, complication-related reoperations and general complications) are recorded up to 30 days after surgery. After 1, 5, and 10 years, patients and primary care physicians are contacted and asked about any pain at rest, pain on exertion, chronic pain requiring treatment or recurrence. This retrospective analysis of prospectively collected data compares the outcomes of minimally invasive vs open techniques in incisional hernia repair after pancreatic surgery.

RESULTS

Relative to the total number of all incisional hernia patients in the Herniamed Registry, the proportion after pancreatic surgery with 1-year follow-up was 0.64% (n = 461) patients. 95% of previous pancreatic surgeries were open. Minimally invasive incisional hernia repair was performed in 17.1% and open repair in 82.9% of cases. 23.2% of the defects were larger than 10 cm and 32.8% were located laterally or were a combination of lateral and medial defects. Among the few differences between the collectives, a significantly higher rate of defect closure (58.1% vs 25.3%; p < 0.001) and drainage (72.8% vs 13.9%; p < 0.001) was found in the open repairs, and larger meshes were seen in the minimally invasive procedures (340.6 cm2 vs 259.6 cm2; p < 0.001). No difference deemed a risk factor for chronic postoperative pain was seen in the rate of preoperative pain between the open and minimally invasive procedures (Appendix Table 4) No significant differences were found in either the perioperative complications or at 1-year follow-up.

CONCLUSIONS

Incisional hernias after complex pancreatic surgery can be repaired safely and with a low recurrence rate in both open and minimally invasive techniques.

Is weight trajectory a better marker of wound complication risk than BMI in hernia patients with obesity?

BACKGROUND

Complex ventral hernias are frequently repaired via an open transversus abdominis release (TAR). Obesity, particularly a BMI > 40, is a strong predictor of wound morbidity following this procedure. We aimed to determine if preoperative weight loss may still be beneficial in patients with persistently elevated BMIs.

METHODS

A retrospective chart review of patients with obesity (BMI ≥ 30) who underwent open TAR at a tertiary academic medical center from January 2018 to December 2021 was completed. Demographics, medical history, operative details, and postoperative data were analyzed. Weight and BMI were recorded at three time points: > 6 months prior to initial surgical consultation, surgical consultation, and day of surgery.

RESULTS

In total, 182 patients with obesity underwent an open TAR. Twenty-seven patients (14.8%) underwent surgery with a BMI > 40; they did not have any significant differences in surgical site occurrences (SSO, 48.1% vs 32.9%, p = 0.13) or surgical site infections (SSI, 25.9% vs 23.2%, p = 0.76) compared to those with a BMI ≤ 40. The average timeframe analyzed for preoperative weight loss was 592 days. Patients who had at least a 3% weight loss (n = 49, 26.9%) had decreased rates of SSI compared to those who did not have this weight loss (12.2% vs 27.8%, p = 0.03), despite the groups having similar BMIs at the time of surgery (36.4 vs 36.0, p = 0.50). Patients who only had a 1% weight loss did not see a decrease in SSI rate compared to those who did not (20.6% vs 25.4%, p = 0.45).

CONCLUSION

Weight loss may be a better indicator of a patient's risk for wound morbidity following TAR than BMI alone, as weight loss of at least 3% resulted in fewer SSIs despite similar BMIs at time of surgery. Further research into optimal timing and amount of weight loss, as well as effects on long-term outcomes, is needed to confirm these findings.

Enhanced recovery after robotic ventral hernia repair: factors associated with overnight stay in hospital

PURPOSE

Enhanced recovery after surgery (ERAS) protocols lead to reduced post-operative stay and improved outcomes after most types of abdominal surgery. Little is known about the optimal post-operative protocol after robotic ventral hernia repair (RVHR), including the potential limits of outpatient surgery. We report the results of an ERAS protocol after RVHR aiming to identify factors associated with overnight stay in hospital, as well as patient-reported pain levels in the immediate post-operative period.

METHODS

This was a prospective cohort study of consecutive patients undergoing RVHR. Patients were included in a prospective database, registering patient characteristics, operative details, pain and fatigue during the first 3 post-operative days and pre- and 30-day post-operative hernia-related quality of life, using the EuraHS questionnaire.

RESULTS

A total of 109 patients were included, of which 66 (61%) underwent incisional hernia repair. The most performed procedure was TARUP (robotic transabdominal retromuscular umbilical prosthetic hernia repair) (60.6%) followed by bilateral roboTAR (robotic transversus abdominis release) (19.3%). The mean horizontal fascial defect was 4.8 cm, and the mean duration of surgery was 141 min. In total, 78 (71.6%) patients were discharged on the day of surgery, and factors associated with overnight stay were increasing fascial defect area, longer duration of surgery, and transverse abdominis release. There was no association between post-operative pain and overnight hospital stay. The mean EuraHS score decreased significantly from 38.4 to 6.4 (P < 0.001).

CONCLUSION

An ERAS protocol after RVHR was associated with a high rate of outpatient procedures with low patient-reported pain levels.

Robotic surgery for inguinal and ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis assessed the effectiveness of robotic surgery compared to laparoscopy or open surgery for inguinal (IHR) and ventral (VHR) hernia repair.

METHODS

PubMed and EMBASE were searched up to July 2022. Meta-analyses were performed for postoperative complications, surgical site infections (SSI), seroma/hematoma, hernia recurrence, operating time (OT), intraoperative blood loss, intraoperative bowel injury, conversion to open surgery, length of stay (LOS), mortality, reoperation rate, readmission rate, use of opioids, time to return to work and time to return to normal activities.

RESULTS

Overall, 64 studies were selected and 58 were used for pooled data analyses: 35 studies (227 242 patients) deal with IHR and 32 (158 384 patients) with VHR. Robotic IHR was associated with lower hernia recurrence (OR 0.54; 95%CI 0.29, 0.99; I2: 0%) compared to laparoscopic IHR, and lower use of opioids compared to open IHR (OR 0.46; 95%CI 0.25, 0.84; I2: 55.8%). Robotic VHR was associated with lower bowel injuries (OR 0.59; 95%CI 0.42, 0.85; I2: 0%) and less conversions to open surgery (OR 0.51; 95%CI 0.43, 0.60; I2: 0%) compared to laparoscopy. Compared to open surgery, robotic VHR was associated with lower postoperative complications (OR 0.61; 95%CI 0.39, 0.96; I2: 68%), less SSI (OR 0.47; 95%CI 0.31, 0.72; I2: 0%), less intraoperative blood loss (- 95 mL), shorter LOS (- 3.4 day), and less hospital readmissions (OR 0.66; 95%CI 0.44, 0.99; I2: 24.7%). However, both robotic IHR and VHR were associated with significantly longer OT compared to laparoscopy and open surgery.

CONCLUSION

These results support robotic surgery as a safe, effective, and viable alternative for IHR and VHR as it can brings several intraoperative and postoperative advantages over laparoscopy and open surgery.

Learning curves of robotic extended totally extraperitoneal (eTEP) hernia repair among two surgeons at a high-volume community hospital: a cumulative sum analysis

INTRODUCTION

Robotic extended totally extraperitoneal hernia (eTEP) repair is a novel technique for minimally invasive ventral hernia repair with retromuscular placement of mesh. This study aimed to evaluate the learning curve for robotic eTEP hernia repair using risk-adjusted cumulative sum (RA-CUSUM) analysis for two general surgeons-one with dedicated fellowship training in robotic eTEP technique (surgeon 2) and another without robotic eTEP-specific training (surgeon 1).

METHODS

We conducted a retrospective analysis of 98 patients undergoing robotic eTEP hernia repair from July 2020 to February 2022 for two surgeons. RA-CUSUM method was applied to the overall operative time (OT) in minutes, adjusting for transversus abdominis release (TAR).

RESULTS

Figures 3 (surgeon 1) and 4 (surgeon 2) illustrate the three phases in the RA-CUSUM graphs of OT. For surgeon 1, the cases for each phase were determined: phase 1 (1 to 12), phase 2 (13 to 24), and phase 3 (25 to 51). For surgeon 2, the three phases were similarly determined as 1 to 8, 9 to 32, and 33 to 47, respectively. A significant (p = 0.017) difference existed for the OTs between phases 1 (262 ± 69) and 3 (192 ± 63.0) for surgeon 1. OT compared to the risk-adjusted value stabilized after case 12 and decreased after case 24 for surgeon 1; it began to decrease after case 8 for surgeon 2.

CONCLUSIONS

The initial learning curve for surgeon 1 reached its plateau after 12 cases, shorter than comparable studies. This was likely due to the surgeon's intentional focus on learning this technique through courses, proctoring, and active mentorship. The flat learning curve seen in surgeon 2's series illustrates the value of experience gained during fellowship training. Our data support that, given the right resources and support, a short learning curve for eTEP is attainable for community surgeons without prior training in the technique.

An improved approach of totally visceral sac separation (TVS) for incisional hernia compared with laparoscopic intraperitoneal onlay mesh plus repair (IPOM plus)

Endoscopic techniques have been widely used in ventral hernia surgery. Totally visceral sac separation (TVS) is a new concept proposed for hernia repair in recent years. The aim of this study was to contrast the postoperative results of TVS with the widely used method of Laparoscopic intraperitoneal onlay mesh plus repair (IPOM plus) for incisional hernias. The retrospective comparison analysis of 38 IPOM plus and 34 TVS was conducted during the time period between December 2019 and June 2022. For both two groups, baseline characteristics, surgical records, postoperative information, and quality of life outcomes utilizing the Carolina's Comfort Scale were collected and analyzed. There were no differences between the methods of TVS and IPOM plus among the baseline characteristics. It showed the operative time in TVS group with the mean time of 213.4 min was significantly longer than that in IPOM plus group with the mean time of 182.9 min (P = 0.010). The postoperative length of stay in TVS group was 6.2 days, which was significantly shorter than IPOM plus group with the mean time of 4.8 days (P = 0.011). The medical expenses was significantly smaller in TVS group than that in IPOM plus group (P < 0.001). The quality of life scores of TVS were significant better than IPOM plus at one week, one month and six months. Besides, both TVS and IPOM plus have very few complications. TVS approach for incisional hernias is secure, effective, and valuable. It has shorter postoperative length of stay, higher quality of life, longer operative time, smaller medical expenses, and approximate complications compared with IPOM plus procedure. Our results have a greater contribution to the application and popularization of TVS technique.

The Role of Robotics in Abdominal Wall Reconstruction

Robotic abdominal wall reconstruction is becoming an accepted technique to approach complex hernias in a minimally invasive fashion. There remain a deficit of high-quality data to suggest significant clinical benefit but current randomized trials are ongoing. Robotic surgery can be applied to a range of abdominal wall defects safely and with positive outcomes which are at least equivocal to open abdominal wall techniques.

Surgeon volumes: preserving appropriate surgical outcomes in higher-risk patient populations undergoing abdominal wall reconstruction

BACKGROUND

It is increasingly recognized that complex abdominal wall reconstruction (cAWR) necessitates specialized training. No studies have been conducted to assess whether a volume-outcomes relationship is present in cAWR. We sought to determine if outcomes for patients undergoing cAWR varied based on surgeon volume among participants in the Abdominal Core Health Quality Collaborative (ACHQC).

METHODS

All patients with ventral hernias undergoing elective cAWR with component separation (lateral component release) were selected from ACHQC database. Surgeons were ranked based on annual number of cAWR procedures performed and then grouped in tertiles. Patient characteristics, hernia risk factors, operative details, and 30-days outcomes were evaluated.

RESULTS

A total of 9206 patients were identified, of which 310 (3.4%), 723 (7.9%) and 8173 (88.7%) cAWRs were performed by low (105 surgeons), medium (49) and high-volume (66) surgeons, respectively. Patients operated upon by high-volume surgeons tended to have more comorbidities and higher ASA class (72.5% of class ≥ III, vs 53.5%). Hernia characteristics demonstrated that high-volume surgeons more commonly operated on patients presenting with recurrent hernias (50.2% vs 42%), wider hernias (13.5 cm vs 10.5 cm), associated ostomies (13% vs 3.6%), and prior of surgical site infections (32% vs 26%, P = 0.035). High-volume surgeons more commonly performed posterior component separation procedures (92% vs 84%), utilized permanent mesh (92% vs 88%), and placed mesh in sublay position. In spite of operating on more advanced hernias, high-volume surgeons achieved comparable rates (all P > 0.4) of 30-day surgical site infections (SSI: 6.9% vs 7.1%) and surgical site occurrences requiring procedural intervention (SSO-PI: 8.9% vs 10%).

CONCLUSIONS

High-volume surgeons maintain comparable outcomes following cAWR despite performing operations on patients with more comorbidities and advanced hernia disease. These findings should be integrated into the debates related to regionalizing abdominal wall reconstruction procedures among high-volume surgeons.

A cost-conscious establishment of a robotic abdominal wall reconstruction program in a publicly funded healthcare system

PURPOSE

Despite reports of better short-term outcomes, the main criticism for the adoption of the robotic surgery platform for abdominal wall reconstruction (AWR) has been the associated cost, especially in countries with a publicly funded healthcare system such as Canada. We describe our experience in implementation of robotic AWR while ensuring cost-effectiveness.

METHODS

This is a retrospective cohort analysis of all patients with ventral hernias ranging between 5 to 15 cm who underwent either open or robotic AWR between January 2020 to August 2022. We reviewed patient characteristics, operative time, post-operative length of stay (LOS), and average cost of surgery.

RESULTS

45 patients underwent open repair and 28 underwent robotic repair in the study period. There was no difference in major patient characteristics between the two groups. Operative time was shorter for open repairs (233.2 ± 96.6 min vs. 299.3 ± 71.8 min, p < 0.001). LOS was significantly longer for open repairs (5 days (interquartile range = 4-6) vs. 2 days (IQR = 1.75-3), p < 0.001) and there were significantly more patients who underwent robotic repair who left hospital in less than 3 days (13.3 vs. 64.3%, p < 0.001). The average overall hospital-based cost for each open repair was $26,952.18 when the cost for equipment, operative time, inpatient hospital stay, and epidural use are accounted for, compared to $17,447.40 for robotic repair ($9,504.78 saving per case).

CONCLUSION

With proper selection of patients based on size of hernia, we demonstrate cost conscious adaptation of the robotic technology to AWR. Our future studies will continue to explore the benefits and limits of this approach in complex hernia repair.

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.

Preliminary robotic abdominal wall reconstruction experience: single-centre outcomes of the first 150 cases

PURPOSE

Robotic surgery offers new possibilities in repairing complex hernias with a minimally invasive approach. This study aimed to analyze our preliminary results.

METHODS

Between November 2015 and February 2020, 150 patients underwent robotic reconstruction for abdominal wall defects (77 primary and 73 incisional). A retrospective analysis of a prospectively maintained database was conducted to evaluate the short-term outcomes.

RESULTS

The mean operative time was 176.9 ± 72.1 min. No conversion to open or laparoscopic approach occurred. The mean hospital length of stay was 2.6 ± 1.6. According to Clavien-Dindo classification, two (grade III) complications following retromuscular mesh placement (1.3%) occurred. One patient (0.7%) required surgical revision due to small bowel occlusion following an intraparietal hernia. The 30-day readmission rate was 0.6%, and the mortality was nihil.

CONCLUSIONS

Robotic surgery is valuable for safely completing challenging surgical procedures like complex abdominal wall reconstruction, with low conversion and complication rates. A stepwise approach to the different surgical techniques is essential to optimize the outcomes and maximize the benefits of the robotic approach.

A comparison of clinical outcomes and costs between robotic and open ventral hernia repair

BACKGROUND

As robotic ventral hernia repair(VHR) adoption increases, real-world evidence is needed to ensure appropriate utilization.

METHODS

Data for open and robotic VHR(OVHR, RVHR) was retrospectively analyzed. Outcomes and costs were compared via inverse probability treatment weighting using propensity scores to estimate the average treatment effect on the treated for RVHR.

RESULTS

675 open and 609 robotic ventral hernia repairs were included. Demographics and hernia characteristics were comparable. Complications rates were lower in RVHR(p < 0.001). Clavien-Dindo grade-III complications were lower in RVHR(13.2% vs. 4.9%, p < 0.001). RVHR resulted in fewer surgical site events(21.5% vs. 12.2%, p < 0.001). Recurrence rates were greater in OVHR(8.9% vs. 2.8%, p < 0.001). The higher RVHR hospital costs (Δ = $2456, p = 0.005) were balanced by the lower post-discharge costs, compared to OVHR(Δ = $799, p = 0.023). Total costs did not differ(Δ = $1656 p = 0.081).

CONCLUSION

Although hospital costs were higher, post-discharge expenses favored RVHR due to the lower postoperative complications, which lead to comparable total costs to OVHR.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic transversus abdominis release: A paradigm shift in complex abdominal wall surgery?

Abdominal wall reconstruction techniques have evolved significantly over the last fifty years and continue to do so at an increasing pace. Beginning with open incisional hernia repair with bilateral rectus myofascial release, multiple techniques to offset tension at the midline by exploring options of layered myofascial release have been described. This article reviews the history, technique, advancements, and future of myofascial release in abdominal wall reconstruction leading from the open Rives-Stoppa repair to the robotic-assisted iteration of the transversus abdominis release.

From transabdominal to totally extra-peritoneal robotic ventral hernia repair: observations and outcomes

PURPOSE

While robotic-assisted hernia repair has increased the popularity of minimally invasive hernia surgery, selecting between the types of approaches is a challenge for both experts and novices alike. In this study, we compared a single surgeon's early experience transitioning from transabdominal hernia repair with sublay mesh in either the pre-peritoneal or retrorectus space (TA-SM) and enhanced-view totally extra-peritoneal (eTEP) ventral hernia repair in the peri-operative and long-term post-operative time periods.

METHODS

We conducted a retrospective review of 50 eTEP and 108 TA-SM procedures to collect demographics, intraoperative details, and 30-day and 1-year post-operative outcomes. Statistical analysis was performed utilizing Chi-square analysis, Fisher's test, and two sample t-tests with equal variances.

RESULTS

There were no significant differences in patient demographics or comorbidities. eTEP patients had larger defects (109.1 cm² vs. 31.8 cm², p = 0.043) and mesh used (432.8 cm² vs. 137.9 cm², p = 0.001). Operative times were equivalent (158.3 ± 90.6 min eTEP and 155.8 ± 65.2 min TA-SM, p = 0.84), but conversion to alternate procedure type was higher for the transabdominal approach (4% eTEP vs. 22% TA-SM, p < 0.05). Hospital stay was less in the eTEP cohort (1.3 days vs. 2.2 days, p < 0.05). Within 30 days, there were no significant differences in emergency visits or hospital readmissions. There was a greater propensity for eTEP patients to develop seromas (12.0% vs. 1.9%, p < 0.05). At 1 year, there was no statistically significant difference in recurrence rate (4.56% eTEP vs. 12.2% TA-SM, p = 0.28) respective to average time to recurrence (9.17 months eTEP vs. 11.05 months TA-SM).

CONCLUSION

The eTEP approach can be adopted safely and efficiently, and may have superior peri-operative outcomes including fewer conversions and reduced hospital stay.

Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure

BACKGROUND

The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based.

METHODS

Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed.

RESULTS

A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44-78)]. Subject matter experts practiced a median of 6.5 years (1.5-16) and have completed a median of 300 (60-500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling.

CONCLUSION

This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

The efficacy of goal-directed recommendations in overcoming barriers to elective ventral hernia repair in older adults

BACKGROUND

Although ventral hernias are common in older adults and can impair quality of life, multiple barriers exist that preclude ventral hernia repair. The goal of this study was to determine if older adults with ventral hernias achieve surgeon-directed goals to progress to an elective ventral hernia repair.

METHODS

Patients ≥60 years evaluated for a ventral hernia in a specialty clinic from January 2018 to August 2021 were retrospectively reviewed. Nonoperative candidates with modifiable risk factors were included. Data collected included specific barriers to ventral hernia repair and recommendations to address these barriers for future ventral hernia repair eligibility. Patients lost to follow-up were contacted by phone.

RESULTS

In total, 559 patients were evaluated, with 182 (32.6%) deemed nonoperative candidates with modifiable risk factors (median age 68 years, body mass index 38.2). Surgeon-directed recommendations included weight loss (53.8%), comorbidity management by a medical specialist (44.0%), and smoking cessation (19.2%). Ultimately, 45/182 patients (24.7%) met preoperative goals and progressed to elective ventral hernia repair. Alternatively, 5 patients (2.7%) required urgent/emergency surgical intervention. Importantly, 106/182 patients (58.2%) did not return to clinic after initial consultation. Of those contacted (n = 62), 35.5% reported failure to achieve optimization goals. Initial body mass index ≥40 and surgeon-recommended weight loss were associated with lack of patient follow-up (P = .01, P = .02) and progression to elective ventral hernia repair (P = .009, P = .005).

CONCLUSION

Nearly one-third of older adults evaluated for ventral hernias were nonoperative candidates, most often due to obesity, and over half of these patients were lost to follow-up. An increase in structured support is needed for patients to achieve surgeon-specified preoperative goals.

Patient-performed at-home surgical drain removal is safe and feasible following hernia repair and abdominal wall reconstruction

BACKGROUND

Traditionally, surgical drains are considered a relative contraindication to telemedicine-based postoperative care. We sought to assess the safety, feasibility, and outcomes of an at-home patient-performed surgical drain removal pilot program.

METHODS

A prospective cohort study among patients who were discharged with surgical drains was performed. Patients discharged with drains were given the option for in-clinic, provider-performed removal, or at-home, patient-performed drain removal. Patient demographics, health characteristics, perioperative metrics, and operative outcomes were compared and analyzed.

RESULTS

A total of 68 encounters with drain removal were included (at-home: 28%, n = 19; in-clinic: 72%, n = 49), with both groups having similar demographics, except for age (median age of telemedicine-based at-home: 50 vs in-clinic: 62 years, p = 0.03). Patients who opted into at-home, patient-performed drain removal were more likely to have drain removal occur earlier (9 vs 13 days for in-clinic, p < 0.001). In-clinic removal resulted in increased encounters with surgical nursing staff and increased travel time, with no significant difference in complication burden.

CONCLUSIONS

Patient-performed at-home drain removal is safe and allows for more timely drain removal.

Robotic repair of pediatric hernias: Current techniques and practices

The use of minimally invasive surgical techniques has gained popularity in pediatric surgery due to decreased length of stay, improved post-operative pain and smaller incisions. Laparoscopic assisted robotic surgical procedures are becoming more common in adults as they carry all of the benefits of traditional MIS but also allow for improved dexterity, visualization and surgeon ergonomics. In adults, hernia repairs are one of the most commonly performed robotic cases but adaption to pediatric repairs has been slower. Case reports and small case series have described a number of various types of pediatric hernia repairs including congenital diaphragmatic hernias, paraesophageal hernias and inguinal hernias. These cases have demonstrated that robotic repair of pediatric hernias is safe and feasible with minimal documented post-operative complications or recurrence. Future directions should focus on larger patient volume in order to assess outcomes between traditional laparoscopic and robotic approaches.

Polypharmacy is predictive of postoperative complications in older adults undergoing ventral hernia repair

BACKGROUND

Ventral hernias are common in older adults, and may be repaired via a transversus abdominus release (TAR). Older adults undergoing surgery have unique age-related risk factors, including polypharmacy. Polypharmacy is highly prevalent in older adults and is associated with adverse postoperative outcomes. Our aim was to examine the prevalence and association of polypharmacy with clinical outcomes in older adults undergoing a TAR.

METHODS

Patients 60 years and older who underwent elective open or robotic bilateral TAR were included in the study. Average daily medications taken preoperatively was collected and stratified by tertiles. Baseline demographic data, peri- and postoperative outcomes, and 30-day outcomes were collected.

RESULTS

There were 132 total patients with an average age of 67.8 years. The number of daily medications ranged from 0 to 28, with an overall mean of 11.2 medications. Patients in tertile 1 took an average of 5.3 medications, tertile 2 10.5 medications, and tertile 3 17.9 medications. Patients in tertile 3 had more than double the rate of in-hospital complications (0.7) compared to tertiles 1 and 2 (0.3 and 0.3, respectively; p = 0.03). A greater number of daily medications was independently associated with postoperative delirium [odds ratio (OR) 1.2, 95% confidence interval (CI) 1.0-1.3], cardiac events (OR 1.2, 95% CI 1.0-1.3), ICU stay (OR 1.2, 95% CI 1.0-1.3), and discharge to a skilled nursing facility (SNF) (OR 1.2, 95% CI 1.0-1.5).

CONCLUSIONS

Polypharmacy was very common in older adults undergoing a TAR, and was associated with in-hospital complications, postoperative delirium, cardiac events, ICU stay, length of stay, and discharge to a SNF. Additional study is needed to assess if preoperative interventions to limit polypharmacy will improve outcomes for older adults undergoing a TAR.

In situ bioprinting: intraoperative implementation of regenerative medicine

Bioprinting has emerged as a strong tool for devising regenerative therapies to address unmet medical needs. However, the translation of conventional in vitro bioprinting approaches is partially hindered due to challenges associated with the fabrication and implantation of irregularly shaped scaffolds and their limited accessibility for immediate treatment by healthcare providers. An alternative strategy that has recently drawn significant attention is to directly print the bioink into the patient's body, so-called 'in situ bioprinting'. The bioprinting strategy and the associated bioink need to be specifically designed for in situ bioprinting to meet the particular requirements of direct deposition in vivo. In this review, we discuss the developed in situ bioprinting strategies, their advantages, challenges, and possible future improvements.

Minimally Invasive Tensiometry: A New Modality for Per-Operative Measurement of Medialization and Tension During Laparoscopic Hernia Surgery

Background: Newly developed techniques for minimally invasive abdominal wall reconstruction (AWR) for complex ventral hernia are continuously evolving. In order to achieve hernia defect closure, the aponeurotic edges of the hernia defect need to be approximated. Currently, surgeons have no way to objectively measure and quantify the traction required to approximate these edges. This study presents minimally invasive tensiometry (MINT), a novel technology for measuring fascial tension, as well as initial experiences and results using it. Methods: The MINT device was designed using rapid prototyping principles. It was designed as an add-on tool for any existing laparoscopic instrument, enabling objective assessment of abdominal wall tension by the use of a manually operated linear spring. Pre-clinical measurements of medialization at 10 and 20 N of tension during AWR were performed on fresh-frozen Post-Mortem Human Specimens (PMHS). Results: Three specimens were included, and a total number of 36 measurements of medialization at three different levels of the abdominal wall were performed under structured and similar circumstances. Median total medialization with 20 Newton (N) of applied tension was 25 mm (mm) cranially, 37.5 mm at the umbilicus and 27.5 mm at the caudal level. The highest rate of medialization was seen at the umbilical level (2.25 mm/N). Conclusion: MINT is a novel non-invasive technique, which allows surgeons to intraoperatively measure fascial tension when performing AWR. The MINT device is easy to use and reproduce. The next step is to start performing clinical measurements applying MINT during AWR.

Midterm Results of the Open and Minimally Invasive Transversus Abdominis Release Technique for the Treatment of Abdominal Wall Hernias in an Academic Center

Introduction: Large hernia defects are a challenge for general and specialized hernia surgeons. The transversus abdominis release (TAR) technique has revolutionized the treatment of complex hernias since it allows the closure of large midline hernias, as well as hernias in different locations. This study aims to report the experience with the TAR technique and mid-term results in the first 101 patients. Methods: Non-concurrent cohort review of our prospectively collected electronic database. All patients submitted to a TAR (open or minimally invasive eTEP-TAR) from 2017 to 2020 were included. Demographic data, comorbidities, hernia characteristics, preoperative optimization, intraoperative variables, and clinical outcomes were gathered. The main outcomes of this study are hernia recurrences and surgical morbidity. Results: A total of 101 patients were identified. The median follow-up was 26 months. Mean age and body mass index was 63 years and 31.4 Kg/m2, respectively. Diabetes was present in 22% of patients and 43% had at least one previous hernia repair. Nineteen patients had significant loss of domain. Mean hernia size and area were 13 cm and 247 cm2, respectively. Ninety-six percent of cases were clean or clean-contaminated. The mean operative time was 164 min and all patients received a synthetic mesh. We diagnosed two hernia recurrences and the overall (medical and surgical) complication rate was 32%. The hernia-specific complication rate was 17%, with seven surgical site infections and seven surgical site occurrences requiring procedural interventions. Notably, weight loss was associated with a lower risk of SSOPI and reoperations. Conclusion: We show an encouraging 2% of recurrences in the mid-term follow-up in the setting of clinically complex hernia repair. However, we observed a high frequency of overall and hernia-specific complications pointing to the complexity of the type of surgery itself and the patients we operated on.

Outcomes of open transverse abdominis release for ventral hernias: a systematic review, meta-analysis and meta-regression of factors affecting them

OBJECTIVES

The primary objectives were to evaluate Surgical Site Occurrences (SSO) and Surgical Site Occurrences requiring procedural Intervention (SSOPI) after open transversus abdominis release and to study various factors affecting it. Secondary objectives were to evaluate Surgical Site Infections (SSI), recurrence rates and overall complications after transversus abdominis release (TAR) and the factors responsible for those.

METHODS

We searched PUBMED, SCOPUS and Cochrane databases with keywords "transversus abdominis release" or "TAR" OR "Surgical Site Occurrences" OR "posterior component separation AND "outcomes" as per PRISMA 2020 and MOOSE guidelines. Full texts and English literature studies were included, studies mentioning outcomes for open transversus abdominis release for ventral hernia were included and studies with robotic transversus abdominis release were excluded. Percentage occurrences of SSO, SSOPI, SSI, recurrence and overall complications after TAR were evaluated. Random effect meta-analysis with restricted maximum likelihood methods was used for meta-analysis. Heterogeneity was analysed using I² statistics. Publication bias with eager's test and funnel plots. Meta0regression analysis was done to evaluate factors affecting the heterogeneity. JASP 0.16.2 software was used for meta-analysis.

RESULTS

Twenty-two studies including 5284 patients who underwent TAR for ventral hernia were included in systematic review and meta-analysis. Overall pooled SSO, SSOPI, Overall Complications, SSI and recurrence rates were 21.72% [95% C.I 17.18-26.27%], 9.82% [95% C.I 7.64 -12%], 33.34% [95% C.I. 27.43-39.26%], 9.13% [95% C.I. 6.41-11.84] and 1.6% [0.78-2.44], respectively. Heterogeneity was significant in all the analysis. Age (p < 0.001), sex (p < 0.001), BMI (p < 0.001),presence of comorbidities (p < 0.001), prior recurrence, defect size (p < 0.001) and current or past history of tobacco exposure were associated with SSO in multivariate meta-regression analysis. Defect size (p = 0.04) was associated with SSOPI. Age (p = 0.011), BMI (p = 0.013), comorbidities (p < 0.01), tobacco exposure (p = 0.018), prior recurrence (p < 0.01) and sex (p < 0.01) were associated with overall complications.

CONCLUSION

Open transversus abdominis release is associated with high rates of SSO, SSOPI, SSI and overall complications but recurrence rates are low. Various preoperative factors mentioned may be responsible for heterogeneity across studies.

Chronological age does not predict postoperative outcomes following transversus abdominis release (TAR)

BACKGROUND

Transversus abdominis release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TAR is not a low risk operation, particularly in older adults who are disproportionately affected by multiple age-related risk factors. While past studies have suggested that age alone inconsistently predicts patient outcomes, data regarding age's effect on postoperative outcomes and wound complications following a TAR are lacking.

METHODS

Patients who underwent either an open or robotic bilateral TAR from 1/2018 to 9/2020 were eligible for the study. Patients were stratified by age groups (≥ 60 years vs. < 60 years and < 60, 60-70, and ≥ 70) and by both age and operative approach. The rates of key postoperative outcomes and wound morbidity were compared between the various cohorts.

RESULTS

A total of 300 patients were included: 165 patients were ≥ 60 and 135 patients were < 60. Cohorts stratified by age were well-matched for important hernia factors: defect size (p = 0.31), BMI ≥ 30 (p = 0.46), OR time (p = 0.25), percent open TAR (p = 0.42), diabetes (p = 0.45) and history of prior surgical site infection (p = 0.40). The older cohort had significantly higher rates of coronary artery disease, hypertension, and COPD. On univariate analysis, cohorts stratified by age had similar rates of key postoperative and wound complications including in-hospital complications (p = 0.62), length of stay (p = 0.47), readmissions (p = 0.66), and surgical site occurrences (p = 0.68). Additionally, cohorts stratified by both age and operative approach also had similar outcomes. Multivariate analysis showed that chronological age was not independently associated with surgical site occurrences (p = 0.22), readmissions (p = 0.99), in-hospital complications (p = 0.15), or severe complications (p = 0.79).

CONCLUSION

Open and robotic TARs can be safely performed in older adults and chronological age alone is a poor predictor of patient morbidity following TAR. Further investigation of alternative preoperative screening tools that do not rely solely on age are needed to better optimize surgical outcomes in older adults following TAR.

Open versus robotic-assisted laparoscopic posterior component separation in complex abdominal wall repair

BACKGROUND

Transversus abdominis release (TAR) is a surgical technique used in the treatment of complex ventral hernias. The aim of this study was to compare outcomes of open (oTAR) versus robotic-assisted (rTAR) posterior component separation by TAR.

METHODS

Consecutive patients at two European hernia centres who underwent bilateral TAR were included. The primary endpoint was the duration of postoperative hospital stay.

RESULTS

Data from 90 rTAR and 79 oTAR operations were evaluated. Patient demographics were similar between groups in terms of age, sex, BMI, and co-morbidities. There were more smokers, and hernias were larger in the oTAR group (width 8.7 cm versus 10.0 cm; P = 0.031, length 11.6 cm versus 14.1 cm; P = 0.005). Duration of postoperative hospital stay was significantly shorter in the rTAR group (3.4 days versus 6.9 days; P < 0.001). Short-term serious complications (Clavien-Dindo grade III and above) were more frequent (20.3 per cent versus 7.8 per cent; P = 0.018), and there were more surgical site infections (12.7 per cent versus 3.3 per cent; P = 0.010) in the oTAR group. During a median follow-up of 19 months in the rTAR group and 43 months in the oTAR group, reoperation (4.4 per cent versus 8.9 per cent; P = 0.245), and recurrence rates (5.6 per cent versus 5.1 per cent; P > 0.009) were similar.

CONCLUSION

Patients with ventral incisional hernias who undergo bilateral rTAR had significantly shorter postoperative hospital stays and fewer short-term complications compared with patients undergoing bilateral oTAR.

Transversus abdominis release with posterior component separation in patients with previously recurrent ventral hernias: A single institution experience

BACKGROUND

Recurrent hernias pose significant challenges due to violated anatomic planes, resultant scar, and potential prior mesh. Transversus abdominis release has been widely utilized for complex hernias. Transversus abdominis release can provide a novel plane for dissection and mesh placement for recurrent hernias. This study provides our institution's experience with transversus abdominis release in patients with recurrent ventral hernias.

METHODS

A retrospective chart review was conducted of patients with recurrent ventral hernias from January 2018 to September 2020 who underwent transversus abdominis release by 2 fellowship-trained abdominal wall surgeons. Combined procedures (ie, gynecological/urological), robotic totally extraperitoneal, and emergency cases were excluded. Demographics, perioperative, and postoperative outcomes were reviewed.

RESULTS

In total, 108 patients underwent open-transversus abdominis release and 25 had robotic-transversus abdominis release for recurrent ventral hernias. All patients received a lightweight to midweight nonabsorbable polypropylene synthetic mesh. Mean age was 59, mean body mass index was 34 kg/m², with mean hernia defect area of 333 cm². We noted 34 (25.6%) surgical site occurrences and 11 (8.3%) surgical site infections. Mean postoperative follow-up was 15.5 months, with 7 (5%) recurrences (6 open-transversus abdominis release, 1 robotic-transversus abdominis release). A minimum 12-month follow-up was available for 62% of patients, and minimum 6-month follow-up in 80% of patients.

CONCLUSION

Recurrent hernias pose significant operative challenges for surgeons due to violated tissue planes and limited repair options. Our experience suggests that transversus abdominis release may provide a durable repair for difficult recurrent ventral hernias. However, long-term postoperative follow-up over multiple years is still needed to establish extended durability of transversus abdominis release in these patients.

Transversus abdominis release (TAR) for ventral hernia repair: open or robotic? Short-term outcomes from a systematic review with meta-analysis

PURPOSE

To compare early postoperative outcomes after transversus abdominis release (TAR) for ventral hernia repair with open (oTAR) and robotic (rTAR) approach.

METHODS

A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Web of Science databases was conducted to identify comparative studies until October 2020. A meta-analysis of postoperative short-term outcomes was performed including complications rate, operative time, length of stay, surgical site infection (SSI), surgical site occurrence (SSO), SSO requiring intervention (SSOPI), systemic complications, readmission, and reoperation rates as measure outcomes.

RESULTS

Six retrospective studies were included in the analysis with a total of 831 patients who underwent rTAR (n = 237) and oTAR (n = 594). Robotic TAR was associated with lower risk of complications rate (9.3 vs 20.7%, OR 0.358, 95% CI 0.218-0.589, p < 0.001), lower risk of developing SSO (5.3 vs 11.5%, OR 0.669, 95% CI 0.307-1.458, p = 0.02), lower risk of developing systemic complications (6.3 vs 26.5%, OR 0.208, 95% CI 0.100-0.433, p < 0.001), shorter hospital stay (SMD - 4.409, 95% CI - 6.000 to - 2.818, p < 0.001) but longer operative time (SMD 53.115, 95% CI 30.236-75.993, p < 0.01) compared with oTAR. There was no statistically significant difference in terms of SSI, SSOPI, readmission, and reoperation rates.

CONCLUSION

Robotic TAR improves recovery by adding the benefits of minimally invasive procedures when compared to open surgery. Although postoperative complications appear to decrease with a robotic approach, further studies are needed to support the real long-term and cost-effective advantages.

Controversies in Abdominal Wall Reconstruction

This article discuses current controversies in abdominal wall reconstruction, including the standardization of outcome reporting, mesh selection, the utility of robotic surgery in ventral hernia repair, and role for prophylactic stoma mesh at the time of permanent end colostomy formation. The current state of the literature pertaining to these topics is reviewed in detail.

ROBotic Utility for Surgical Treatment of hernias (ROBUST hernia project)

We describe the evolution in hernia repair approaches in our practice during the first 3 years of adopting robotic assisted laparoscopic surgery. For inguinal hernia repair, we began using the robotic platform for complex hernias, and the use of open repair decreased from 17% to 6%. For primary ventral hernias, open procedures decreased from 59% to 10% and for incisional ventral hernias, from 48% to 11%. Moreover, a large shift in mesh position for ventral hernias was seen, with an increase of the retromuscular position from 20% to 82% and a decrease of intraperitoneal mesh position from 48% to 10%. The robotic platform seems to hold a significant potential for complex inguinal hernias, in addition to ventral and incisional hernias which require component separation. A shorter hospital stay and less postoperative complications might make the adoption of the robotic platform for abdominal wall surgery a valuable proposition.