Comparative review of outcomes: laparoscopic and robotic enhanced-view totally extraperitoneal (eTEP) access retrorectus repairs

IPOM versus eTEP as minimally invasive approaches for ventral/incisional hernias: a systematic review and meta-analysis

PURPOSE

Enhanced-view totally extraperitoneal (eTEP) repair of ventral hernias is an emerging modality that places synthetic mesh in the retrorectus space and obviates its fixation. We aimed to compare outcomes between eTEP and minimally invasive intraperitoneal onlay mesh (IPOM) repair techniques.

METHODS

A PRISMA-compliant meta-analysis searching PubMed, EMBASE and CENTRAL databases from January 2010 till August 2024, was performed. All studies comparing IPOM versus eTEP were included. The primary objective was postoperative pain at day 7 (POD7) whereas secondary objectives included operative time, length of stay (LOS), intraoperative and postoperative complications and recurrence. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed.

RESULTS

Twelve studies (3 randomized, 9 observational) capturing 868 patients (452 IPOM, 416 eTEP) were included. Most hernias were primary ventral (n = 806). Most studies (10/12) adopted a laparoscopic approach whilst two employed robotic techniques. IPOM was associated with significantly higher pain scores at POD7 (VAS; visual analog scale; MD 3.01, 95%CI = 1.28-4.75, p = 0.0007), longer LOS (MD 0.65 days, 95%CI = 0.27-1.04, p = 0.001) but shorter operative time (MD - 53.69 min, 95%CI = - 69.65- - 37.73, p < 0.00001). However, there was no differences in intraoperative (OR 2.04, 95%CI = 0.81-5.17, p = 0.13), postoperative (OR 1.15, 95%CI = 0.54-2.46, p = 0.72) complications or recurrence (OR 2.08, 95%CI = 0.79-5.46, p = 0.14). On sensitivity analyses, comparing laparoscopic IPOM with defect closure (IPOM +) versus eTEP, similar results prevailed.

CONCLUSIONS

IPOM(+) is associated with more postoperative pain at one week and a longer hospital stay. However, no differences were observed in complications or recurrence between the two techniques.

Early postoperative outcomes in a retrospective propensity score-matched comparison of robotic extended totally extraperitoneal (r-eTEP) and extended totally extraperitoneal (eTEP) repair for ventral hernia

BACKGROUND

The extended totally extraperitoneal technique (eTEP) is a novel approach for ventral hernia repair. This technique has been recently advanced using robotics (r-eTEP). The aim of this study is to perform a comprehensive analysis of the initial results of r-eTEP and to evaluate the safety and efficacy of this technique compared to the eTEP technique.

METHODS

This is a monocentric retrospective study of patients with ventral hernias who underwent surgery via eTEP or r-eTEP in our department between 2019 and 2023. Propensity score matching was applied to compare the groups. Preoperative patient and hernia characteristics, intraoperative findings, and postoperative outcomes were subsequently analysed.

RESULTS

Patient demographics were comparable between the groups. The r-eTEP group had a significantly greater proportion of M3 hernias (p = 0.006), M4 hernias (p = 0.020), incisional hernias (p = 0.002), and hernias with rectus diastasis (p < 0.001). The r-eTEP group had a significantly larger hernia defect (p = 0.003) and larger mesh size (p = 0.015). The r-eTEP group had a shorter hospital stay (p < 0.001) and shorter operative time, though not statistically significant (p = 0.211). Intraoperative and postoperative complications, as well as postoperative pain, were comparable between the groups.

CONCLUSION

The findings of the present study show that the r-eTEP technique may offer potential benefits as the overall hospital stay was shorter while intraoperative and postoperative complications were comparable for both techniques.

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.

Mini-invasive surgery for diastasis recti: an overview on different approaches

Diastasis recti abdominis (DRA) is an acquired condition defined by a widening of the linea alba exceeding 2 cm and the subsequent separation between the two medial margins of the rectus muscles, accompanied by a laxity of the ventral abdominal muscles, and often by ventral midline hernias. It is a quite common problem in women after pregnancy. In addition to the aesthetic implications resulting from the swelling of the anterior abdominal wall in the case of increased pressure within the abdominal cavity, DRA leads to several physical functional disorders, including muscle weakness, prolapses of the pelvic organs, urinary and fecal incontinence, low back and pelvic pain and sexual dysfunction. The management of diastasis recti can be conservative, with physiotherapy and specific physical exercises, but, especially in case of concomitant hernia, surgery can be considered as the first choice of treatment in order to restore the midline and repair the hernia. Through recent years, a large amount of mini-invasive surgical techniques has been proposed, approaching the abdominal differently, and to date there is still lack of evidence on the optimal choice for surgeons and patients. So, the present review aims to give the reader an overview on the different techniques proposed, focusing on the three main categories of approaches (pre-aponeurotic, retro-muscular and pre-peritoneal), their specific features and results, with a view on the newly proposed robotic approaches that can theoretically reproduce each single technique.

Robotic extended total extraperitoneal transversus abdominus release for traumatic flank and abdominal intercostal hernias

PURPOSE

Traumatic abdominal intercostal/flank hernias present a perplexing challenge for surgeons seeking to repair them. There has been a paucity of studies describing robotic repairs of such hernias. We aim to evaluate the effectiveness of the Robotic-assisted Extended Total Extraperitoneal/Transversus Abdominus Release (rETEP/TAR) method in repairing traumatic abdominal intercostal and flank hernias.

METHODS

Patients with traumatic abdominal intercostal hernias at a high-volume hernia center between 2019 and 2022 were identified and retrospective data including patient demographics, perioperative parameters, postoperative complications and up to a three-year follow-up were collected for those undergoing rETEP/TAR. Robotic ETEP access was gained through the retro-rectus space ipsilateral to the hernia, using a transversus abdominis release performed laterally to the level of the posterior axillary line. Dissection was completed from the pelvis to the central tendon as necessary.

RESULTS

A total of 8 patients were analyzed. All patients suffered traumatic or Valsalvainduced hernias. The average age was 54 +/-15yrs. The mean defect size was 11x17cm. Heavyweight uncoated polypropylene mesh was placed in the retromuscular space and secured with transfascial suture. Mean mesh size was 34x30cm and mean operative time was 216 +/- 69 minutes. The median length of stay was 1 day. All patients reported improvement in pain without any evidence of recurrence at postoperative follow-up.

CONCLUSION

This study demonstrates that the Robotic-assisted ETEP/TAR technique is an effective way of repairing abdominal intercostal and flank hernias.

Comparative approach for abdominal wall reconstruction after ventral hernia: open versus minimally invasive surgery

INTRODUCTION

The classic open ventral hernia repair provides excellent results in recurrences. However, wound complications are the Achilles heel for a good overall clinical outcome. Laparoscopic surgery is in general associated with less pain, better esthetic results, faster recovery, and lower incidence of wound complications. Robotic procedures provide increased degrees of freedom, may improve ergonomics, and allow scaling and performance of finer movements deemed difficult through alternate surgical approaches.

PURPOSE

The aim of this study is to compare outcomes between open and minimally invasive approaches, with the primary objective of determining differences in postoperative course and hospitalization.

METHODS

Patients underwent any of the three procedures: open Rives-Stoppa, laparoscopic eTEP or robotic eTEP between June 2020 and January 2024 for the treatment of one or more midline abdominal wall hernias alongside rectus abdominis diástasis. The width diameter of the hernias was between 3 and 10 cm and techniques that did not place the mesh in a retromuscular position or required component separation are excluded.

RESULTS

Robotic surgery had a lower score on the visual analogue scale for pain at discharge (p-value < 0.00). Minimally invasive surgery allows for the placement of larger meshes compared to the open approach (p < 0.05), although the surgical time is longer (p-value < 0.00). There were no statistically significant differences for hospital stay (p-value = 0.46), complications (p-value = 0.52) or recurrence (p-value = 0.70).

CONCLUSION

Minimally invasive surgery allows for the placement of larger meshes compared to the open approach without increasing the morbidity of the procedure or the immediate postoperative pain, despite generally having longer operative times.

Endoscopic enhanced-view totally extraperitoneal prosthetic (eTEP) versus open Rives-Stoppa repair as a treatment of midline abdominal wall hernias with rectus diastasis: comparison of postoperative pain and length of hospital stay in a single-centre surgical cohort

The Rives-Stoppa (RS) procedure is a gold standard treatment of midline abdominal wall hernias. Comparability of pain control and outcomes to the enhanced-view totally extraperitoneal prosthetic (eTEP) repair remain unclear. A single-centre retrospective surgical cohort was selected including 30 RS repairs (January 2019-November 2021) and 30 consecutive eTEP procedures (September 2021-August 2022) for midline abdominal wall hernia(s) with rectus abdominis diastasis. Postoperative pain and outcomes were compared up to 1 month. Presence and median duration of patient-controlled analgesia were, respectively, 90% and 3 nights with RS, versus 30% and 0 nights with eTEP. Median switch to only oral analgesics occurred at postoperative day (POD) 3 after RS and at POD 2 after eTEP. Postoperative analgesics and opioid prescription at discharge were comparable. Median length of hospital stay was six nights after RS versus 3 nights after eTEP. Median duration of surgery was 110.5 and 164.5 min for RS and eTEP, respectively. After RS, 30 patients had postoperative drain(s) compared to 3 patients after eTEP. Conversion was needed in 3 eTEP procedures. Postoperative complications were comparable. No early recurrences were observed. Minimal residual diastasis was seen at postoperative consultation in 11 patients after eTEP. Compared to RS, eTEP is a minimally invasive alternative treatment of midline abdominal wall hernias with rectus abdominis diastasis and is associated with a shorter length of hospital stay, less postoperative pain and a comparable risk of short-term complications. At 1 month after eTEP, minimal residual diastasis can be present. ClinicalTrials.gov: NCT05446675. Secondary identifying number: EC/EH/220608-SK. Date of Registration: June 24, 2022.

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.

End-Tidal CO2 During Enhanced-View Totally Extraperitoneal Hernia Repair: A Comparison of Retrorectus and Intraperitoneal Insufflation

INTRODUCTION

Although the enhanced-view totally extraperitoneal (eTEP) approach has demonstrated safety, efficacy, and durability for small- to medium-sized hernia repairs, the relationships between retrorectus insufflation, intraoperative respiratory stability, and end-tidal CO2 (ETCO2) levels has not been appraised.

METHODS

We conducted a retrospective chart review of patients undergoing elective robotic-assisted ventral hernia repairs at our quaternary academic center from July 2018 through December 2021. Patients were grouped by repair technique, either eTEP or robotic transversus abdominis release (r-TAR). Baseline demographics, intraoperative anesthesia records, and perioperative outcomes were reviewed. Anesthesia data were collected at intubation and 30-min time intervals thereafter. Operative time, length of stay, patient-controlled anesthesia use, and perioperative complications were compared.

RESULTS

In total, 205 patients underwent an eTEP repair and 97 patients underwent an r-TAR repair. Intraoperatively, eTEP repairs had significantly higher ETCO2 at the beginning of the case (times 1-4, P < 0.05), and a higher peak ETCO2 (P < 0.05) when compared to r-TAR repairs. This difference in ETCO2 desisted as the case progressed, with a subsequent increase in respiratory rate (times 2-6, P < 0.05) in the eTEP procedures. The eTEP group demonstrated significantly shorter operative times, decreased patient-controlled anesthesia use, and a shorter length of stay. There was no significant difference in postoperative intensive care unit admission or respiratory distress.

CONCLUSIONS

This study demonstrates that retrorectus insufflation during eTEP hernia repairs correlated with higher levels of ETCO2 compared to r-TAR repairs yet was not associated with any meaningful difference in perioperative outcomes. Communication of these respiratory differences with anesthesia is needed for proper ventilation adjustments.

EARLY OUTCOMES OF ROBOTIC ENHANCED VIEW TOTALLY EXTRAPERITONEAL VENTRAL HERNIA REPAIR: A SINGLE-CENTER EXPERIENCE

BACKGROUND

Incisional hernia (IH) is an abdominal wall defect due to a previous laparotomy, and surgical repair is the only treatment. IH has a negative impact on patients' quality of life. In the last decades, the approach has improved from open to laparoscopic and robotic surgery with the objective of promoting better abdominal wall function after reconstruction. Today, robotic enhanced-view totally extraperitoneal (reTEP) is one of the most advanced techniques for abdominal wall reconstruction.

AIMS

The aim of this study was to analyze the early results of patients with incisional hernia submitted to repair with reTEP.

METHODS

This is a retrospective cohort study, and all patients who underwent reTEP surgery for ventral hernia in the years 2021 and 2022 were included. The only exclusion criteria were patients who underwent another type of herniorrhaphy. Statistical analysis was performed using the Stata software.

RESULTS

A total of 32 participants were submitted to reTEP; the majority had an incisional hernia, and according to the European Hernia Society, EUS-M score 3 was the most prevalent. The mean surgical time was 170 min, and the console time was 142 min. Most patients stayed 2 days in the hospital. No intraoperative complications were reported.

CONCLUSIONS

reTEP is a safe and effective technique and has favorable outcomes in the early postoperative period. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings.

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.

Drain vs no drain placement after retromuscular ventral hernia repair with mesh: an ACHQC analysis

INTRODUCTION

Ventral hernia repair (VHR) is one of the most common procedures in the United States, and drains are used in over 50% of mesh repairs. The aim of this study is to investigate the impact of drains on surgical site occurrences (SSO) and infection (SSI) after open and minimally invasive retromuscular VHR with mesh.

METHODS

A retrospective review of prospectively collected data from the ACHQC was performed to include adult patients who underwent elective VHR with retromuscular mesh placement. Univariate analysis was performed comparing drain and no-drain groups. A logistic regression was performed to identify factors independently associated with increased SSO, SSI, readmission, and length of stay (LOS).

RESULTS

6945 patients underwent elective VHR with sublay mesh. Most patients had M2 and M3 hernias in both groups (with Drain and no-drain). The median LOS was 4.7 (SD 8.3) in the drain group and 1.6 (SD 8.4) in the no-drain group (p < 0.001). 30-day SSI was higher in the drain group (176; 3.8% vs 25; 1.1%; p < 0.001). Despite lower SSO overall in the drain group (470; 10.0% vs 286; 12.7%; p < 0.001), SSO or SSI requiring intervention (SSOPI) was higher in the drain group (240; 5.1% vs 44; 1.9%; p < 0.001). Logistic regression identified diabetes (OR 1.3, CI 1.1-1.6; p < 0.001) and BMI (OR 1.04, CI 1.03-1.05; p < 0.001) as predictors of SSO, while the use of a drain was protective (OR 0.61; CI 0.5-0.8; p < 0.001). For SSI, logistic regression showed diabetes (OR 1.6, CI 1.2-2.3; p = 0.004) and open approach (OR 3.5, CI 2.1-5.9; p < 0.001) as predictors.

CONCLUSIONS

Drain placement during retromuscular VHR with mesh was predictive of decreased postoperative SSO occurrence but associated with increased LOS. Diabetes and open approach, but not drain use, were predictors of SSI.

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).

Implementation of the Versius Surgical System in Complex Abdominal Wall Repair: First Reported Case of an Robotic ETEP/TAR Procedure

BACKGROUND

Robotic ventral hernia repair has been increasing globally, with comparable outcomes to laparoscopic repair and lower rates of conversion to open surgery. Robotic surgery is increasing in popularity, and there is a number of new robotic systems entering the marketing. We report the first case of a Roboic eTEP using the Versius robotic system in a patient with an incisional hernia.

METHODS

Surgery was performed using the Versius system from CMR surgical which consists of bedside units for each instrument and a console. The patient presented with an incisional hernia measuring 9.5×5 cm in the left flank.

RESULTS

The patient was discharged on postoperative day (POD) 2 with a drain. There was no need for opioids. The drain was removed at POD 7. The patient presented at POD 10 with erythema and cellulitis in the area that previously had tape on it, and it was resolved with a short course of oral antibiotics.

CONCLUSION

The eTEP technique for hernia surgery was safe and feasible using the Versius robotic system. Implementation is possible in experienced hands with minimal changes to the surgical techniques.

Analysis of retromuscular drain output and postoperative outcomes for heavyweight versus mediumweight polypropylene mesh following open ventral hernia repair

PURPOSE

Heavyweight polypropylene (HWPP) mesh is thought to increase inflammatory response and delay tissue integration compared to mediumweight (MWPP). Reactive fluid volume (i.e., drain output) may be a reasonable surrogate for integration. We hypothesized that daily drain output is higher with HWPP compared to MWPP in open retromuscular ventral hernia repair (VHR).

METHODS

This is a post-hoc analysis of a multicenter, randomized clinical trial conducted March 2017-April 2019 comparing MWPP and HWPP for VHR. Retromuscular drain output in milliliters was measured at 24-h intervals up to postoperative day seven. Univariate analyses compared differences in daily drain output and time to drain removal. Multivariable analyses compared total drain output and wound morbidity within 30 days and hernia recurrence at 1 year.

RESULTS

288 patients were included; 140 (48.6%) HWPP and 148 (51.4%) MWPP. Daily drain output for days 1-3 was higher for HWPP vs. MWPP (total volume: 837.8 mL vs. 656.5 mL) (p < 0.001), but similar on days 4-7 (p > 0.05). Median drain removal time was 5 days for both groups. Total drain output was not predictive of 30-day wound morbidity (p > 0.05) or hernia recurrence at 1 year (OR 1, p = 0.29).

CONCLUSION

While HWPP mesh initially had higher drain outputs, it rapidly returned to levels similar to MWPP by postoperative day three and there was no difference in clinical outcomes. We believe that drains placed around HWPP mesh can be managed similarly to MWPP mesh.

Initial experience with enhanced recovery after surgery (ERAS) and early discharge protocols after robotic extended totally extraperitoneal (eTEP) hernia surgery

BACKGROUND

Though robotic adoption for eTEP surgery has decreased technical barriers to minimally invasive repairs of large ventral hernias, relatively few studies have examined outcomes of robotic-specific eTEP surgery. This study evaluates safety, feasibility, and early outcomes of ERAS/same-day discharge protocols for robotic eTEP ventral hernia repairs.

METHODS

A retrospective chart review was performed for all robotic eTEP hernia surgeries at a single institution between 2019 and 2022. Analysis included patient demographics, hernia characteristics, intraoperative data, and post-operative outcomes at 30 days. ERAS protocol included: judicious use of urinary catheters with removal at end of case if placed, bilateral transversus abdominus plane (TAP) blocks, post-operative abdominal wall binder, and opioid-sparing perioperative analgesia. Patients were discharged same day from post-anesthesia care unit (PACU) if they lacked comorbidities requiring observation post-anesthesia and demonstrated stable vital signs, adequate pain control, ability to void, and ability to ambulate. Hospital length of stay (LOS) was considered 0 for same-day PACU discharges or hospitalizations < 24 h.

RESULTS

102 patients were included in this case series. 69% (70/102) of patients were discharged same-day (mean LOS 0.47 ± 0.80 days). Within 30 post-operative days, 3% (3/102) of patients presented to the ER, 2% (2/102) were readmitted to the hospital, and 1% (1/102) required reoperation. There was 1 serious complication (Clavien-Dindo grade 3/4) with an aggregate complication rate of 7.8%.

CONCLUSIONS

Our initial experience with ERAS protocols and same-day discharges after robotic eTEP repair demonstrates this approach is safe and feasible with acceptable short-term patient outcomes. Compared to traditional open surgery for large ventral hernias, robotic eTEP may enable significant reductions in hospital LOS as adoption increases.

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.

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.

Robotic approach for retromuscular ventral hernia repair may be associated with improved wound morbidity in high-risk patients: a propensity score analysis

BACKGROUND

Retromuscular sublay (RMS) technique for repair of ventral hernias has gained popularity due to lower risk of recurrence and wound complications. Robotic approaches to RMS have been shown to decrease hospital stay; however, previous studies have failed to show a significant reduction in wound morbidity. Utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database, this study sought to determine the effect of robotic approach on wound morbidity, while specifically focusing on a high-risk population.

METHODS

A retrospective review of elective robotic and open RMS repairs in the ACHQC database was performed. Patients deemed to be high-risk for wound complications were included: adult patients with BMI greater than 35 and who were either current smokers or diabetics. A propensity score match was then done to balance covariates between the two groups. Main outcomes of concern were surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrence requiring procedural intervention (SSOPI) at 30-day follow-up.

RESULTS

A total of 917 patients met inclusion criteria. After propensity score matching, 211 patients matched for each approach. There was no difference in overall SSO (18% for Open vs 23% for Robotic, p = 0.23). Open repair was associated with higher rates of SSI (4% vs 1%, p = 0.032) and SSOPI (9% SSOPI vs 3%, p < 0. 015). As seen in previous studies, there was a higher rate of seroma associated with Robotic RMS repair (87% vs 48%, p < 0.001) in patients that developed an SSO.

CONCLUSIONS

In this analysis, a robotic approach was associated with decreased rates of SSI and SSOPI in obese patients who were either current smokers or diabetics. In effort to reduce wound morbidity and the associated physical and economic costs, robotic approach for retromuscular ventral hernia repair should be considered in this patient population.

Intraoperative complications of robotic-assisted extended totally extraperitoneal (eTEP) ventral hernia retromuscular repairs with mesh: a systematic literature review and narrative synthesis

Minimally invasive extended totally extraperitoneal (eTEP) technique is revolutionising ventral hernia repairs. Robotic-assisted eTEP has been gaining popularity due to better visual clarity and greater dexterity provided by the robotic systems, compared to laparoscopy. Despite growing number of papers being published each year, so far, no study has explored intraoperative complications in robotic-assisted eTEP. The aim was to perform a systematic literature review on the incidence of intraoperative complications in robotic-assisted eTEP ventral hernia repairs. The study protocol was preregistered with PROSPERO, registration number CRD42023450072. Twelve categories of intraoperative complications were defined by the authors. A search of PubMed and Embase was conducted on 16/08/2023, for articles pertaining to robotic-assisted eTEP operations in ventral hernias in adults. Articles were critically appraised and data were extracted using predefined extraction templates. No data were suitable for statistical analysis and a narrative synthesis was performed instead. Ten studies fulfilled the inclusion criteria, of which four studies reported intraoperative complications. Of the 12 categories of intraoperative complications, only 5 were reported. Three studies encountered adherent bowel inside the hernia sac. One reported linea alba injury with subsequent anterior layer dehiscence. There was one case of unrecognised intraoperative retromuscular bleeding and one case of insufflation injury with subcutaneous emphysema. There is a paucity of literature on the incidence of intraoperative complications in robotic-assisted eTEP ventral hernia repairs. Available studies suggest complication rates are low. More robust studies using prospective data from hernia registries are required before further conclusions can be drawn.

Quality of life, post-operative complications, and hernia recurrence following enhanced-view Totally Extra-Peritoneal (eTEP) Rives-Stoppa for incisional and primary ventral hernia repair

The purpose of this study was to evaluate the quality of life (QoL), early post-operative complications, and hernia recurrence rate following laparoscopic enhanced-view Totally Extra-Peritoneal (eTEP) Rives-Stoppa (RS) for incisional and primary ventral hernia repair. Retrospective review of a prospectively maintained database of all patients undergoing eTEP-RS between 2017 and 2020. Data retrieved included demographics, and clinical and operative variables. QoL was assessed using the EuraHS-QoL scale prior to- and following eTEP-RS. During the study period, 61 patients met the inclusion criteria. Age and BMI were 62 (60.4 ± 13.8) years and 29.7 (30.4 ± 6) kg/m2, respectively. Incisional hernia was the most common pathology (n = 40, 65%) followed by primary ventral hernia (n = 21, 35%), with 24 patients (39%) having a previous hernia repair. Diastasis-recti repair was undertaken in 34 patients (55%), a concomitant inguinal hernia was repaired in 6 patients (10%), and 13 patients (21%) underwent transversus abdominis release (TAR). Median follow-up time was 13 months and 15 patients (25%) had at least 2 years of follow-up. Hernia recurrence was found in 4 patients (6.5%). Pre-operative and post-operative EuraHS-QOL questionnaire scores were available for 46 patients (75%) and showed significant improvement in pain (7 vs. 0.5, p < 0.0001; 5 vs. 0.5, p < 0.0001; 5 vs. 1.5; p < 0.006), restrictions (median of 5 vs. 0.5, p < 0.0001; 5 vs. 0, p < 0.0001; median of 5 vs. 1, p < 0.0001, of 6.5 vs. 1.5, p < 0.0001), and cosmetic appearance (8 vs. 4, p < 0.0001). Abdominal wall repair using the eTEP-RS approach significantly improves subjective QoL variables with an acceptable post-operative complications and hernia recurrence rates in a short-term follow-up.

Enhanced-view totally extraperitoneal access for repair of ventral hernias: Advantages and liabilities

The concept of enhanced-view totally extraperitoneal (eTEP) access was developed while exploring ways to facilitate the TEP approach for inguinal hernia repair. Surgeons soon noticed that the surgical space was ideal for repair of other abdominal hernias. The "crossover" maneuver, designed as a technique to cross from one retrorectus space to the other, permitted application of eTEP access to most hernias. eTEP access has the general advantage of working in the extraperitoneal space and the specific advantage of hernia repair allowing implementation of the modern principles of ventral hernia reconstruction and providing flexibility to address different types of hernias in different locations. The technique requires formal training and has inherent complications and limitations. The remarkable widespread acceptance and encouraging early results of this complex technique emphasize the responsibilities of proper training, judicious use, and evaluation of our own and others' results.

Drain placement in retromuscular ventral hernia repair: a systematic review and meta-analysis

PURPOSE

Drain placement in retromuscular ventral hernia repair is controversial. Although it may reduce seroma formation, there is a concern regarding an increase in infectious complications. We aimed to perform a meta-analysis on retromuscular drain placement in retromuscular ventral hernia repair.

METHODS

We performed a literature search of Cochrane, Scopus and PubMed databases to identify studies comparing drain placement and the absence of drain in patients undergoing retromuscular ventral hernia repair. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I² statistics.

RESULTS

3808 studies were screened and 48 were thoroughly reviewed. Four studies comprising 1724 patients were included in the analysis. We found that drain placement was significantly associated with a decrease in seroma (OR 0.34; 95% CI 0.12-0.96; P = 0.04; I² = 78%). Moreover, no differences were noted in surgical site infection, hematoma, surgical site occurrences or surgical site occurrences requiring procedural intervention.

CONCLUSIONS

Based on the analysis of short-term outcomes, retromuscular drain placement after retromuscular ventral hernia repair significantly reduces seroma and does not increase infectious complications. Further prospective randomized studies are necessary to confirm our findings, evaluate the optimal duration of drain placement, and report longer-term outcomes.

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.

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.

Patient-reported outcomes of laparoscopic versus robotic primary ventral and incisional hernia repair: a systematic review and meta-analysis

BACKGROUND

Patient-Reported Outcome Measures (PROM's) are increasingly used to assess surgical outcomes in low-risk surgeries such as minimally invasive primary ventral and incisional hernia repair. The purpose of this meta-analysis was to systematically summarize the available evidence for the effect of laparoscopic versus robotic primary ventral and incisional hernia repair on PROM's.

METHODS

A systematic review and meta-analysis were performed in accordance with PRISMA guidelines. Randomised control trials, retrospective and prospective studies were included. Medline, Embase, SCOPUS, Web of Science, and Cochrane CENTRAL, and two trial registers were searched. Pooled effect sizes and 95% confidence intervals were calculated using the Mantel-Haenszel method. The overall quality of evidence was assessed using GRADE.

RESULTS

Of the 2728 titles screened, eight studies involving 41,205 participants were included. Return to activities of daily living, return to work day and recurrence rate were statistically better in the robotic group. Length of stay, readmission, postoperative pain, quality of life, body image, and patient satisfaction were similar in both groups. The GRADE rating of the quality of evidence was moderate for postoperative pain and low to very low for the quality of life, length of stay, recurrence and readmission.

CONCLUSION

The available data of PROM's of laparoscopic and robotic primary ventral and incisional hernia repair is scarce and highly heterogeneous, thus making it difficult to assess the superiority of the laparoscopic technique over the robotic technique. Further studies with uniform reporting of PROM's in laparoscopic and robotic primary ventral and incisional hernia repair are needed.

Learning Curve of Robotic Enhanced-View Extraperitoneal Approach for Ventral Hernia Repairs

Introduction: The enhanced-view extraperitoneal (eTEP) technique was first described for minimally invasive inguinal hernia repairs and later for laparoscopic ventral hernia repair. The objective of this study was to report our early experience and learning curve (LC) with the robotic-assisted eTEP (R-eTEP) approach. Materials and Methods: We performed a retrospective analysis of patients undergoing R-eTEP repair for ventral hernias from December 2018 to September 2021. A single surgeon operative time (OT)-based LC was evaluated. Results: A total of 81 patients underwent an R-eTEP from December 2018 to September 2021. Sixty-five patients were ultimately included in our analysis. Fifty-seven patients underwent eTEP-Rives-Stoppa (RS) and 8 patients underwent eTEP-transversus abdominis release (TAR). The median age in the whole cohort was 57 years (interquartile range [IQR] 51.5-64.5 years) with no difference between the groups. The median body mass index (BMI) was 31 kg/m² (IQR 27-34.7 kg/m²) in the eTEP-RS group and 29.7 kg/m² (IQR 28.5-31 kg/m²) in the eTEP-TAR group. There were 36 incisional hernias (63%) in the eTEP-RS group and 8 (100%) in the eTEP-TAR group. There were 14 recurrent hernias (25%) in the eTEP-RS group and 2 (25%) in the eTEP-TAR group. The LC was evaluated only in the eTEP-RS cases. We divided the cohort into 3 chronological groups (G1, G2, and G3), including 19 cases each. The median OT in each group was 177 (IQR 147-200), 153 (IQR 127-187), and 125 minutes (IQR 106-152 minutes), respectively. There was no difference in the median OT between G1 and G2 (P = .390). G3 had a shorter median OT than G2 (P = .02) and G1 (P = .001). There was no difference between these groups in median age, BMI, defect area, defect width, and mesh area. Conclusions: The R-eTEP approach has been shown to be safe and feasible for ventral and incisional hernia repairs. A statistically significant decrease in OT was observed after 38 cases.

Pitfalls and complications of enhanced-view totally extraperitoneal approach to abdominal wall reconstruction

BACKGROUND

The enhanced-view totally extraperitoneal access technique (eTEP) to minimally invasive retromuscular abdominal wall reconstruction is a relatively novel technique that has continued to gain popularity. There is a paucity of information regarding the prevention and management of eTEP complications. We reviewed the literature to evaluate the complications reported with eTEP ventral hernia repair and discuss the main complications associated with this technique.

METHODS

A literature search via PubMed was performed focusing on eTEP ventral hernia repair. Based on the available literature and own practice experience, the authors discuss key strategies for preventing and managing complications associated with the eTEP approach.

RESULTS

One hundred fifty studies were identified. Forty-seven studies were fully reviewed and twenty-four were included in this review. The technical details of the technique were described as performed by the authors. Postoperative complications were classified into different categories and discussed separately.

CONCLUSION

As the eTEP approach continues to gain popularity, it is essential to consider its unique complications. A focus on prevention with anatomical bearings and sound surgical technique is paramount.

An Algorithmic Approach for the MIS Repair of Ventral Midline Hernias Associated With Diastasis of the Rectus Abdominis Muscle

Purpose: We present our algorithmic approach for symptomatic ventral hernias with Diastasis of the Rectus Abdominis Muscle (DRAM). Methods: Retrospective analysis of patients with symptomatic ventral hernias and DRAM undergoing hernia repair and plication of DRAM from July 2018-March 2021 was conducted. Based on our algorithm, patients were selected for an Endoscopic Onlay Repair (ENDOR) or a Robotic Extended Totally Extraperitoneal Ventral Repair (R-eTEP). Results: We performed a R-eTEP in fifty-seven patients and an ENDOR in twenty-four patients. In the R-eTEP group, thirty-seven (65%) patients were female, the mean age was 54.8 (±10.6), and the mean BMI was 32 (±4.8). Fifty patients (87.7%) had multiple defects, of which 19 (38%) were recurrent hernias and 31 (62%) were incisional hernias. The mean operative time was 200 (±62.4) minutes, with two cases requiring a hybrid approach. The median length of stay was 1 day (0-12), and the median follow-up was 103 days. Twenty-four patients underwent an ENDOR, 19 females (79.2%), the mean age was 45.7 years (±11.7) and the mean BMI was 28 (±3.6). 13 patients had isolated umbilical or epigastric hernias. The mean operative time was 146.2 min (±51.1). Fibrin sealant and suture was the predominant method for mesh fixation, and most cases were performed in an ambulatory setting. Four patients developed post-operative seromas; one requiring drainage due to infection. The Median follow-up was 48.5 days (10-523), with two reported hernia recurrences. Conclusion: An algorithmic approach for adequate patient selection was shown to be safe for treating ventral hernias with DRAM.

Establishment of minimally invasive ventral hernia repair with extraperitoneal mesh placement in a primary care hospital using the robotic platform

Background

The progressive availability of robotic surgical systems opens new perspectives in abdominal wall surgery due to excellent visibility and dexterity of instruments. While complex hernias until today were treated primarily through an open access, we evaluated if this promising technology is suitable for treating the entire spectrum of a hernia center, including complex hernias.

Material/methods

In 2017, minimally invasive hernia surgery with extraperitoneal mesh placement was started in Kempten hospital. Since 2019, a Da Vinci X system has been available for this purpose. In order to observe the process of transition we retrospectively analyzed all patients who underwent ventral hernia repair in the department of general and visceral surgery at our hospital between January 2016 and December 2020 and were indicated for mesh implantation.

Results

In 2016, the percentage of minimally invasive procedures was 37.3%. In all of these cases an intraperitoneal mesh was implanted into the abdominal cavity. Open surgery was performed in 62.7%, of which an a retromuscular mesh was implanted in 75.7%, an intraperitoneal mesh in 21.6%, and an onlay mesh in 2.7%. In 2020, minimally invasive surgery accounted for 87.5%, of which 85.7% were performed robotically and 14.3 laparoscopically. In 94.3% of these minimally invasively treated patients the mesh was implanted in extraperitoneal position (75.8% in retromuscular and 24.2% in preperitoneal position). The percentage of complex hernias increased from 20.3% to 35.0% during the same period.

Conclusion

The majority of ventral hernia procedures can be performed safely using the robot in a minimally invasive technique with extraperitoneal mesh placement without leading to an increase in complications. Robotically-assisted hernia repair is a promising new technique that is also practical for complex hernias.

Three-Year Clinical Outcomes and Quality of Life after Retromuscular Resorbable Mesh Repair Using Fibrin Glue

BACKGROUND

With 400,000 hernias repaired annually, there is a need for development of efficient and effective repair techniques. Previously, the authors' group compared perioperative outcomes and hospital costs of patients undergoing ventral hernia repair with retromuscular mesh using suture fixation versus fibrin glue. This article reports on 3-year postoperative outcomes, including hernia recurrence, long-term clinical outcomes, and patient-reported quality of life.

METHODS

Patients who underwent ventral hernia repair performed by a single surgeon between 2015 to 2017 were identified. Patients with retromuscular resorbable mesh placed were included and matched by propensity score. Primary outcomes included hernia recurrence, surgical-site infection, surgical-site occurrence, and surgical-site occurrence/surgical-site infection requiring procedural interventions. Secondary outcomes included quality of life as assessed by the Hernia-Related Quality of Life Survey.

RESULTS

Sixty-three patients were eligible, and 46 patients were matched (23 suture fixation and 23 fibrin glue), with a median age of 62 years, a median body mass index of 29 kg/m2, and a median defect size of 300 cm2 (interquartile range, 180 to 378 cm2). Median follow-up was 36 months (interquartile range, 31 to 36 months). There was no difference in the incidence of hernia recurrence (13.0 percent for suture fixation and 8.7 percent for fibrin glue; p = 0.636) or other postoperative outcomes between techniques (all p > 0.05). Five patients required reoperation because of a complication (10.9 percent). Overall quality of life improved preoperatively to postoperatively at all time points (all p < 0.05), and no differences in quality-of-life improvement were seen between techniques (p > 0.05).

CONCLUSION

Ventral hernia repair with atraumatic resorbable retromuscular mesh fixation using fibrin glue demonstrates equivalent postoperative clinical and quality-of-life outcomes when compared to mechanical suture fixation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparative review of outcomes: single-incision laparoscopic total extra-peritoneal sub-lay (SIL-TES) mesh repair versus laparoscopic intraperitoneal onlay mesh (IPOM) repair for ventral hernia

To compare outcomes between single-incision laparoscopic totally extra-peritoneal sub-lay (SIL-TES) mesh repair and laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernia (VH). A retrospective selection of 104 patients who underwent VH repair (50 and 54 in the SIL-TES and IPOM groups, respectively) was made. Patient data were collected, and quality of life was evaluated using Carolinas Comfort Scale (CCS) 1 month and 3 months after surgery. There were no significant differences in sex, American Society of Anesthesiologists class, defect size, mesh area, estimated blood loss, and complication rate between the groups. Age was lower, body mass index was higher, prevalence of primary VH was significantly higher (p < 0.0001), and pain was less at 24 and 48 h post procedure (p < 0.0001) in the SIL-TES group. Drainage placement was more (p < 0.0001), operation time was shorter (p = 0.012), and hospitalization duration and total hospitalization cost were greater in the IPOM group than that in SIL-TES group (8.3 ± 0.3 vs 4.3 ± 0.4 days, p < 0.0001; $7126.9 ± 141.4 vs $2937.3 ± 58.3, p < 0.0001, respectively). Pain and movement limitation scores evaluated by CCS were significantly worse at 1 month (4.93 ± 0.28 vs 1.75 ± 0.28: p < 0.0001; 2.52 ± 0.24 vs 1.15 ± 0.18: p < 0.0001, respectively) and 3 months (4.32 ± 0.37 vs 0.9 ± 0.29: p < 0.0001; 2.06 ± 0.25 vs 0.69 ± 0.11: p < 0.0001, respectively) in IPOM group, compared with the according scores in SIL-TES group. There was no readmission within 30 days and no hernia recurrence at mean follow-up of 12 months. SIL-TES mesh repair is safe and effective and is superior to IPOM repair.

Favourable outcomes after Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Non-Complex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-Analysis

OBJECTIVE

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

SUMMARY BACKGROUND DATA

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For non-complex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

METHODS

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

RESULTS

Ninety-three studies representing 12440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% (95%CI: 2.2-4.2%, n = 11049) after minimally 12 months and 4.1%, (95%CI: 2.9-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2-6.4%, n = 4891) and 5.5% (95%CI: 4.4-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (OR: 0.27, 95%CI: 0.15-0.51, p < 0.001) and equal recurrence rates compared to intraperitoneal onlay (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03-3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8-2.8%, n = 982), albeit based on non-randomized studies.

CONCLUSIONS

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except surgical site infection. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

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

Background

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

Study design

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

Results

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

Conclusion

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

Supplementary Information

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

Clinical outcomes and cost of robotic ventral hernia repair: systematic review

BACKGROUND

Robotic ventral hernia repair (VHR) has seen rapid adoption, but with limited data assessing clinical outcome or cost. This systematic review compared robotic VHR with laparoscopic and open approaches.

METHODS

This systematic review was undertaken in accordance with PRISMA guidelines. PubMed, MEDLINE, Embase, and Cochrane databases were searched for articles with terms relating to 'robot-assisted', 'cost effectiveness', and 'ventral hernia' or 'incisional hernia' from 1 January 2010 to 10 November 2020. Intraoperative and postoperative outcomes, pain, recurrence, and cost data were extracted for narrative analysis.

RESULTS

Of 25 studies that met the inclusion criteria, three were RCTs and 22 observational studies. Robotic VHR was associated with a longer duration of operation than open and laparoscopic repairs, but with fewer transfusions, shorter hospital stay, and lower complication rates than open repair. Robotic VHR was more expensive than laparoscopic repair, but not significantly different from open surgery in terms of cost. There were no significant differences in rates of intraoperative complication, conversion to open surgery, surgical-site infection, readmission, mortality, pain, or recurrence between the three approaches.

CONCLUSION

Robotic VHR was associated with a longer duration of operation, fewer transfusions, a shorter hospital stay, and fewer complications compared with open surgery. Robotic VHR had higher costs and a longer operating time than laparoscopic repair. Randomized or matched data with standardized reporting, long-term outcomes, and cost-effectiveness analyses are still required to weigh the clinical benefits against the cost of robotic VHR.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature.

METHODS

A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic.

RESULTS

In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification.

CONCLUSION

Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Employing a Xiphoid-umbilicus Approach in an Endoscopic Totally Extraperitoneal Procedure for the Preperitoneal Repair of Midline Ventral Hernias

OBJECTIVES

Endoscopic totally extraperitoneal sublay (TES) repair seems to be a promising procedure for treating ventral hernias because repairing at the preperitoneal layer reduces damage to the natural musculoaponeurotic structures of the abdominal wall. This article reports the preliminary surgical results after such a procedure with a xiphoid-umbilicus approach for a midline ventral hernia of the middle-upper abdomen.

MATERIALS AND METHODS

Fifteen cases with a small midline ventral hernia scheduled for preperitoneal repair with a TES procedure with a xiphoid-umbilicus approach were included. Patient demographics, hernia characteristics, operative variables, and surgical results were recorded and analyzed.

RESULTS

The patients' average age was 55.80±15.33 years, body mass index was 26.49±2.98, defect size was 4.59±2.28 cm2, and the most frequent region was M3. Five of 15 procedures were conducted in a bottom-up direction, and 10 of 15 with single-port surgery. Only 1 repair failed due to severe peritoneal damage. The operation duration was 120.4±47.7 minutes. All patients recovered quickly and uneventfully, and no case needed readmission. No severe intraoperative and postoperative complications occurred. Only 1 case developed seroma, and there was no surgical site infection, pain, trocar site hernia, and recurrence observed during short-term follow-up (3 to 12 mo).

CONCLUSIONS

Endoscopic preperitoneal repair helps reduce damage to the abdominal wall during a TES procedure. Compared with a suprapubic approach, employing a xiphoid-umbilicus approach facilitates preperitoneal repair for small ventral hernias of the middle-upper abdomen. This will be a future option for minimally invasive surgical repair of such ventral hernias (Supplemental Digital Content 1, Video, http://links.lww.com/SLE/A287).

Laparo-Endoscopic Repair of Ventral Hernia and Rectus Diastasis

Background:

Both umbilical and epigastric hernias may be associated with rectus muscle divarication. In such cases, isolated repair of combined hernia defects can have high recurrence rates and poorer cosmetic outcomes, thus the repair of both pathologies ought to be favored. The goal of the study below is to provide detailed technical aspects of the endoscopic retro-rectus mesh repair.

Methods:

We chose a group of 16 patients who underwent the repair of ventral hernias associated with both primary and incisional rectus diastasis, using the extended-view of a totally extraperitoneal Rives-Stoppa repair (eRives) technique. All defects were < 6 cm in width. Our outcome measures perioperative complications and early recurrences.

Results:

The approach used in our study has led to zero cases of perioperative complications and only one early recurrence.

Conclusions:

We believe that the e-Rives repair is the optimal approach for ventral hernias associated with diastasis recti. This technique additionally produces favorable cosmetic outcomes that granted our results a well-deserved recognition in the medical literature.

Extended totally extraperitoneal Rives-Stoppa (eTEP-RS) technique for ventral hernia: initial experience of The Wall Hernia Group and a surgical technique update

The enhanced-view extended totally extraperitoneal (eTEP) approach for ventral hernia repair is a novel surgical technique. We present the results from the initial experience with eTEP repair Rives-Stoppa (eTEP-RS) at two Italian centers, and we provide an update on this approach. Between December 2018 and July 2020, 19 patients suffering from ventral hernia were treated with the eTEP-RS. Patients' characteristics, operative details, and complications were analyzed. The median follow-up time was 16 (range 6-24) months. Thirteen (68.4%) patients with ventral incisional hernias and 6 (31.6%) with primary ventral hernia underwent an eTEP-RS procedure. The average defect area was 21 cm² and the prosthesis's average size was 380 cm². We registered complications in two cases (10.5%); 1 patient had an asymptomatic seroma (Clavien-Dindo grade 1), and another had intestinal obstruction on the 10th postoperative day (Clavien-Dindo grade 3B). The mean hospital stay was 3.9 (range: 2-6) days. There was no hernia recurrence. The eTEP-RS is a feasible and safe approach in ventral hernia repair with minimally invasive surgery. Further studies are needed to define patients' selection and to know long-term outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Image Inversion during Xi Robotic ventral hernia repair: making it even more effective

INTRODUCTION

currently, there are several clinical applications for robot-assisted surgery and in the hernia scenario, robot-assisted surgery seems to have the ability to overcome laparoscopic ventral hernias repairs limitations, facilitating dissection, defect closure, and mesh positioning. Exponentially grown in numbers of robotic approaches have been seen and even more complex and initially not suitable cases have recently become eligible for it. An appropriate tension-free reestablishment of the linea alba is still a major concern in hernia surgery and even with the robotic platform, dissecting and suturing in anterior abdominal wall may be challenging. This article reports a technical image artifice during a da vinci Xi-platform robotic ventral hernia repair allowing the surgeon to establish a more familiar and ergonomic manner to perform dissection and suturing in anterior abdominal wall.

TECHNICAL REPORT

a step by step guided technique of image inversion artifice is described using detailed commands and figures to assure optimal surgical field and ergonomics whenever acting in robotic ventral hernias repair with the da Vinci Xi-platform. Our group brief experience is also reported, showing an easy and reproducible feature among surgeons with safe outcomes.

CONCLUSION

we consider that image inversion artifice is a simple and reproducible feature in robotic ventral hernia repair. Through a step-by-step guide, this report enables the creation of an artifice providing a comfortable operative field and allowing the surgeon to achieve its best proficiency in hernia surgery.

Laparoscopic intraperitoneal versus enhanced-view totally extraperitoneal retromuscular mesh repair for ventral hernia: a retrospective cohort study

BACKGROUND

Laparoscopic enhanced-view totally extraperitoneal retromuscular repair (eTEP-RM) was recently introduced as a new technique for ventral hernia repair. The aim of the current study was to examine the outcomes of laparoscopic eTEP-RM compared with laparoscopic IPOM for patients with primary ventral and incisional hernia.

METHODS

This was a retrospective cohort study of patients undergoing laparoscopic ventral hernia repair at a single University Hospital from June 2017 to November 2020. Medical charts of all patients subjected to IPOM and eTEP-RM were evaluated to identify patient- and procedure related variables, as well as postoperative 30-day outcomes.

RESULTS

A total of 72 patients were included in the study, 43 and 29 of whom underwent IPOM and eTEP-RM repair, respectively. Patient demographics showed no differences in terms of gender, age, smoking and comorbidity. The median age was 57 years and body mass index 30.5 kg/m². The rate of patients with incisional hernia was higher in the IPOM group (39.5% vs. 20.7%, p = 0.154). There was no difference in horizontal and vertical hernia size defect. The duration of surgery was significantly shorter for IPOM (mean 82.4 vs. 103.4 min, p = 0.010), whereas the length of stay was significantly longer after IPOM (median 1 days vs. 0 days (p < 0.001). The rate of patients requiring postoperative transversus abdominis plane (TAP) block or epidural analgesia was significantly higher after IPOM (33% vs. 0%, p = 0.002). A subgroup analysis on patients undergoing primary ventral hernia showed similar results.

CONCLUSION

The study found laparoscopic eTEP-RM safe and effective compared to traditional laparoscopic IPOM. The patients undergoing eTEP-RM had significantly reduced need for additional analgesic treatment and length of stay.

Impact of Body Mass Index (BMI) on perioperative outcomes following minimally invasive retromuscular abdominal wall reconstruction: a comparative analysis

BACKGROUND

Morbidity and recurrence rates are higher in obese patients undergoing open abdominal wall reconstruction (AWR). Historically, body mass index (BMI) ≥ 40 has served as a relative contraindication to open AWR. The purpose of this study is to evaluate the impact of minimally invasive surgery (MIS) on outcomes after AWR for higher versus lower BMI patients.

METHODS

A retrospective review of a prospectively maintained database was conducted of all patients who underwent MIS AWR between September 2015 and April 2019 at our institution. Patients were subdivided into two groups based on their BMI: BMI ≤ 35 kg/m² and BMI > 35 kg/m². Patient demographics and perioperative data were evaluated using univariate and multivariate analysis.

RESULTS

461 patients were identified and divided into two groups: BMI ≤ 35 (n = 310) and BMI > 35 (n = 151). The two groups were similar in age (BMI ≤ 35: 56.3 ± 14.1 years vs. BMI > 35: 54.4 ± 11.9, p = .154). BMI > 35 group had more patients with ASA score of 3 (81% vs. 32%, p < .001) and comorbid conditions such as hypertension (70% vs. 45%, p < .001), diabetes mellitus (32% vs. 15%, p < .001), and history of recurrent abdominal wall hernia (34% vs. 23%, p = .008). BMI > 35 group underwent a robotic approach at higher rates (74% vs. 45%, p < .001). Patients who underwent a Rives-Stoppa repair from the higher BMI cohort also had a larger defect size (5.6 ± 2.4 cm vs. 6.7 ± 2.4 cm, p = .004). However, there were no differences in defect size in patients who underwent a transversus abdominus release (BMI ≤ 35: 9.7 ± 4.9 cm vs. BMI > 35: 11.1 ± 4.6 cm, p = .069). Both groups benefited similarly from a short length of stay, similar hospital charges, and lower postoperative complications.

CONCLUSION

Initial findings of our data support the benefits of elective MIS approach to AWR for patients with higher BMI. These patients derive similar benefits, such as faster recovery with low recurrence rates, when compared to lower BMI patients, while avoiding preoperative hernia incarceration, postoperative wound complications, and hernia recurrences. Future follow-up is required to establish long-term perioperative and quality of life outcomes in this patient cohort.

Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias

OBJECTIVES

described by Dr. Jorge Daes, principles of the enhanced view totally extraperitoneal (eTEP) has been widely used in the armamentarium of ventral hernia repair recently. Robotic assisted eTEP technique feasibility has been proved, however, a complete understanding of retromuscular abdominal wall planes and its landmarks still uncertain in a majority of general surgeons. The aim of this report is to propose a technical standardization and its anatomic concepts in the robotic-assisted eTEP ventral hernia repair.

METHODS

our group describes 10 key steps in a structured step-by-step approach for a safe and reproducible repair based on well defined anatomic landmarks, identification of zones of dissection and correct restoration of the linea alba.

RESULTS

the standardization has been developed 2 years ago and applied to all patients. A robotic-assisted surgery with 3 robotic arms is performed in a lateral docking setup. Feasibility is established and reproducibility is high among general surgeons.

CONCLUSION

we present a standardized side docking robotic assisted eTEP approach for ventral hernia repairs with 10 key steps. We believe understanding the landmarks and a step-by-step guidance based on the concepts of retromuscular abdominal wall anatomy foment a safe learning of minimally invasive restoration of the abdominal wall integrity regarding non-expert surgeons.

A preliminary multicenter evaluation of endoscopic sublay repair for ventral hernia from China

Background

For ventral hernia, endoscopic sublay repair (ESR) may overcome the disadvantages of open sublay and laparoscopic intraperitoneal onlay mesh repair. This retrospective study presents the preliminary multicenter results of ESR from China. The feasibility, safety, and effectiveness of ESR were evaluated; its surgical points and indications were summarized.

Methods

The study reviewed 156 ventral hernia patients planned to perform with ESR in ten hospitals between March 2016 and July 2019. Patient demographics, hernia characteristics, operative variables, and surgical results were recorded and analyzed.

Results

ESR was performed successfully in 153 patients, 135 with totally extraperitoneal sublay (TES) and 18 with transabdominal sublay (TAS). In 19 patients, TES was performed with the total visceral sac separation (TVS) technique, in which the space separation is carried out along the peritoneum, avoiding damage to the aponeurotic structure. Endoscopic transversus abdominis release (eTAR) was required in 17.0% of patients, and only 18.3% of patients required permanent mesh fixation. The median operative time was 135 min. Most patients had mild pain and resume eating soon after operation. No severe intraoperative complications occurred. Bleeding in the extraperitoneal space occurred in two patients and was stopped by nonsurgical treatment. Seroma and chronic pain were observed in 5.23 and 3.07% of patients. One recurrence occurred after TAS repair for an umbilical hernia.

Conclusion

ESR is feasible, safe, and effective for treating ventral hernias when surgeons get the relevant surgical skills, such as the technique of “partition breaking,” TVS, and eTAR. Small-to-medium ventral hernias are the major indications.

Patients with ineffective esophageal motility benefit from laparoscopic antireflux surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common chronic disorder of the gastrointestinal tract, affecting more than 50% of Americans. The development of GERD may be associated with ineffective esophageal motility (IEM). The impact of esophageal motility on outcomes post laparoscopic antireflux surgery (LARS), including quality of life (QOL), remains to be defined. The purpose of this study is to analyze and compare QOL outcomes following LARS among patients with and without ineffective esophageal motility (IEM).

METHODS

This is a single-institution, retrospective review of a prospectively maintained database of patients who underwent LARS, from January 2012 to July 2019, for treatment of GERD at our institution. Patients undergoing revisional surgery were excluded. Patients with normal peristalsis (non-IEM) were distinguished from those with IEM, defined using the Chicago classification, on manometric studies. Four validated QOL surveys were used to assess outcomes: Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL), Laryngopharyngeal Reflux Health-Related QOL (LPR-HRQL), and Swallowing Disorders (SWAL) survey.

RESULTS

203 patients with complete manometric data were identified (75.4% female) and divided into two groups, IEM (n = 44) and non-IEM (n = 159). IEM and Non-IEM groups were parallel in age (58.1 ± 15.3 vs. 62.2 ± 12 years, p = 0.062), body mass index (27.4 ± 4.1 vs. 28.2 ± 4.9 kg/m², p = 0.288), distribution of comorbid disease, sex, and ASA scores. The groups differed in manometry findings and Johnson-DeMeester score (IEM: 38.6 vs. Non-IEM: 24.0, p = 0.023). Patients in both groups underwent similar rates of Nissen fundoplication (IEM: 84.1% vs. Non-IEM: 93.7%, p = 0.061) with greater improvements in dysphagia (IEM: 27.4% vs. 44.2%) in Non-IEM group but comparable benefit in reflux reduction (IEM: 80.6% vs. 72.4%) in both groups at follow-up. There were no differences in postoperative outcomes. Satisfaction rates with LARS were similar between groups (IEM: 80% vs. non-IEM: 77.9%, p > 0.05).

CONCLUSION

Patients with ineffective esophageal motility derive significant benefits in perioperative and QOL outcomes after LARS. Nevertheless, as anticipated, their baseline dysmotility may reduce the degree of improvement in dysphagia rates post-surgery compared to patients with normal motility. Furthermore, the presence of preoperative IEM should not be a contraindication for complete fundoplication. Key to optimal outcomes after LARS is careful patient selection based on objective perioperative data, including manometry evaluation, with the purpose of tailoring surgery to provide effective reflux control and improved esophageal clearance.

The current state of robotic retromuscular repairs-a qualitative review of the literature

BACKGROUND

The management of ventral incisional hernias (VIH) has undergone many iterations over the last 5 years due to evolution in surgical techniques and advancement in robotic surgery. Four general principles have emerged: mesh usage, retromuscular mesh placement, primary fascial closure, and usage of minimally invasive techniques when possible. The application of robotic retromuscular repairs in VIH allow these principles to be applied simultaneously. This qualitative review attempts to answer what robotic retromuscular repairs are described, which patients are selected for these techniques, and what are current outcomes.

METHODS

Using the key words: "robotic retromuscular repair", "robotic Rives Stoppa", and "robotic transversus abdominis release", a PubMed search of articles written up to December 2019 was critically reviewed.

RESULTS

44 articles were encountered, 9 high-quality articles were analyzed for this manuscript. Level of evidence ranged from 2B to 2C. Robotic TAR patients had BMI of 33 kg/m², defect sizes ranging from 7-14 cm wide to 12-19 cm long, longer OR times, no difference in surgical site events, and shorter length of stay (LOS). The techniques to perform robotic Rives Stoppa (RS) were heterogeneous; however, extended totally extraperitoneal (ETEP) approach is most described. Defect width for RS repairs ranged 4-7 cm and LOS was less than 1 day. Complication rates were low, there is no long-term data on hernia recurrence, and information on cost is limited.

CONCLUSION

In short-term follow-up, robotic retromuscular repairs show promise that VIH can be repaired with intramuscular mesh, few complications, and shorter LOS. Data on hernia recurrence, long-term complications, and rigorous cost analysis are needed to demonstrate generalizability.

Robotic versus laparoscopic ventral hernia repair: multicenter, blinded randomized controlled trial

OBJECTIVE

To determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair.

DESIGN

Pragmatic, blinded randomized controlled trial.

SETTING

Multidisciplinary hernia clinics in Houston, USA.

PARTICIPANTS

124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019.

INTERVENTIONS

Robotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59).

MAIN OUTCOME MEASURES

The primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat.

RESULTS

Patients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair.

CONCLUSION

This study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03490266.