Abdominal core quality of life after ventral hernia repair: a comparison of open versus robotic-assisted retromuscular techniques

Surgical Approach and Long-Term Recurrence After Ventral Hernia Repair

Importance

The prevalence of robotic-assisted anterior abdominal wall (ventral) hernia repair has increased dramatically in recent years, despite conflicting evidence of patient benefit. Whether long-term hernia recurrence rates following robotic-assisted repairs are lower than rates following more established laparoscopic or open approaches remains unclear.

Objective

To evaluate the association between robotic-assisted, laparoscopic, and open approaches to ventral hernia repair and long-term operative hernia recurrence.

Design, Setting, and Participants

Secondary retrospective cohort analysis using Medicare claims data examining adults 18 years and older who underwent elective inpatient ventral, incisional, or umbilical hernia repair from January 1, 2010, to December 31, 2020. Data analysis was performed from January 2023 through March 2024.

Exposure

Operative approach to ventral hernia repair, which included robotic-assisted, laparoscopic, and open approaches.

Main Outcomes and Measures

The primary outcome was operative hernia recurrence for up to 10 years after initial hernia repair. To help account for potential bias from unmeasured patient factors (eg, hernia size), an instrumental variable analysis was performed using regional variation in the adoption of robotic-assisted hernia repair over time as the instrument. Cox proportional hazards modeling was used to estimate the risk-adjusted cumulative incidence of operative recurrence up to 10 years after the initial procedure, controlling for factors such as patient age, sex, race and ethnicity, comorbidities, and hernia subtype (ventral/incisional or umbilical).

Results

A total of 161 415 patients were included in the study; mean (SD) patient age was 69 (10.8) years and 67 592 patients (41.9%) were male. From 2010 to 2020, the proportion of robotic-assisted procedures increased from 2.1% (415 of 20 184) to 21.9% (1737 of 7945), while the proportion of laparoscopic procedures decreased from 23.8% (4799 of 20 184) to 11.9% (946 of 7945) and of open procedures decreased from 74.2% (14 970 of 20 184) to 66.2% (5262 of 7945). Patients undergoing robotic-assisted hernia repair had a higher 10-year risk-adjusted cumulative incidence of operative recurrence (13.43%; 95% CI, 13.36%-13.50%) compared with both laparoscopic (12.33%; 95% CI, 12.30%-12.37%; HR, 0.78; 95% CI, 0.62-0.94) and open (12.74%; 95% CI, 12.71%-12.78%; HR, 0.81; 95% CI, 0.64-0.97) approaches. These trends were directionally consistent regardless of surgeon procedure volume.

Conclusions and Relevance

This study found that the rate of long-term operative recurrence was higher for patients undergoing robotic-assisted ventral hernia repair compared with laparoscopic and open approaches. This suggests that narrowing clinical applications and evaluating the specific advantages and disadvantages of each approach may improve patient outcomes following ventral hernia repairs.

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.

Robotic repair of moderate-sized midline ventral hernias reduced complications, readmissions, and length of hospitalization compared to open techniques

PURPOSE

To compare outcomes of robotic and open repair for uncomplicated, moderate-sized, midline ventral hernias.

METHODS

From 2017 to 2021, patient characteristics and 30 day outcomes for all ventral hernias at our center were prospectively collected. We studied hernias potentially suitable for robotic repair: elective, midline, 3-10 cm rectus separation, no prior mesh, and no need for concomitant procedure. Robotic or open repair was performed by surgeon or patient preference. The primary outcome was any complication using Clavien-Dindo scoring. Secondary outcomes were operative time, length-of-stay, and readmissions. Regression identified predictors of complications.

RESULTS

Of 648 hernias repaired, 70 robotic and 52 open repairs met inclusion criteria. The groups had similar patient demographics, co-morbidities, and hernia size, except that there were more immunosuppressed patients in the open group (11 versus 5 patients, p = 0.031). Complications occurred after 7 (13%) open repairs versus 2 (3%) robotic repairs, p = 0.036. Surgical site infection occurred after four open repairs but no robotic repair, p = 0.004. Length-of-stay averaged almost 3 days longer after open repair (4.3 ± 2.7 days versus 1.5 ± 1.4 days, p = 0.031). Readmission occurred after 6 (12%) oppen repairs but only 1 (1%) robotic repair. A long-term survey (61% response rate after mean follow-up of 2.8 years) showed that the HerQLes QOL score was better after robotic repair (46 ± 15 versus 40 ± 17,  = 0.049). In regression models, only open technique predicted complications.

CONCLUSIONS

Robotic techniques were associated with fewer complications, shorter hospitalization, fewer infections, and fewer readmissions compared to open techniques. Open surgical technique was the only predictor of complications.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

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 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.

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.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Assessment of Quality of Life After Ventral Hernia Repair: A Prospective Observational Study at a Tertiary Care Centre

Background Ventral hernias are usually repaired by an open or laparoscopic approach. Quality of life after ventral hernia repair is a very important but often underestimated parameter. This prospective observational study was conducted to assess the quality of life and other related parameters after all types of ventral hernia repair, mainly between open and laparoscopic repairs.  Objectives This study aimed to determine the quality of life after ventral hernia repairs. We also analysed and compared various parameters such as outcomes and satisfaction, postoperative pain, and complications between laparoscopic and open ventral hernia repair.  Methods This was a hospital-based prospective observational study conducted from January 2020 to December 2021, which included a total of 70 patients with ventral hernias. Thirty-nine patients underwent open repair and 31 patients underwent laparoscopic repair. Demographic data and other data such as postoperative hospital stay, return to activity, postoperative pain, complications, and quality of life were collected and analysed. Results The distribution of different types of hernias observed in our study included 34% incisional hernias, 33% umbilical and paraumbilical hernias, and 33% epigastric hernias. The incidence of complications was significantly less in laparoscopic repair compared to open repair. Also, satisfaction at 1 month was significantly more in the laparoscopic group compared to the open group. However, there is no significant difference in the postoperative pain, postoperative hospital stay, return to activity, satisfaction at discharge, and quality of life at 1 month in both the laparoscopic and open repairs.  Conclusion Laparoscopic ventral hernia repairs are associated with lesser complications and higher satisfaction. The use of tackers and trans-fascial sutures can significantly increase postoperative pain in laparoscopic repair and is the major factor affecting the short-term quality of life in laparoscopic repairs. As there is no difference in postoperative pain, hospital stay, and return to activity, laparoscopic repairs should be preferred wherever possible in view of fewer complications and higher satisfaction.

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.

Robotic Surgery: At the Crossroads of a Data Explosion

BACKGROUND

For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016].

METHODS

This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes.

RESULTS

Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information.

CONCLUSION

Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].

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.

Greatest Quality of Life Improvement in Patients With Large Ventral Hernias: An Individual Assessment of Items in the HerQLes Survey

BACKGROUND

Ventral hernia repair (VHR) has been shown to improve overall quality of life (QOL) by the validated 12-question Hernia-Related Quality-of-Life survey (HerQLes). However, which specific aspects of quality of life are most affected by VHR have not been formally investigated.

METHODS

Through retrospective analysis of the Abdominal Core Health Quality Collaborative national database, we measured the change in each individual component of the HerQLes questionnaire from a pre-operative baseline assessment to one-year postoperatively in VHR patients.

RESULTS

In total, 1,875 VHR patients had completed both pre- and post-operative questionnaires from 2014-2018. They were predominately Caucasian (92.3%), 57.9 ± 12.4 Y old, and evenly gender split (50.5% male, 49.5% female, P = 0.31). Most operations were performed open (80.5%) with fewer laparoscopic (7.5%) or robotic cases (12.1%). For each of the 12 individual categories, improvement in QOL from baseline to 1-Y was found to be statistically significant (P < 0.0001). This held true with subgroup analysis of small (<2 cm), medium (2-6 cm), and large (>6 cm) hernias (P < 0.0001), though a larger improvement was seen in 8 of 12 components in hernias >6 cm (P < 0.001). Operative approach did not carry a significant effect except in medium hernias (2-6 cm), where an open approach saw a greater improvement in the "accomplish less at work" item (P = 0.02).

CONCLUSIONS

VHR is associated with improvement in each of the 12 components of QOL measured in the HerQLes questionnaire, regardless of the size of their hernia. The amount of improvement, however, may be dependent on hernia size and approach.

Preoperative exercise and outcomes after ventral hernia repair: Making the case for prehabilitation in ventral hernia patients

BACKGROUND

An increasing body of information suggests that preoperative physical activity level can impact postoperative outcomes. We sought to investigate this relationship in patients undergoing ventral hernia repair (VHR).

METHODS

The Abdominal Core Health Quality Collaborative registry was used to identify patients undergoing a VHR between 2013 and 2019. Patient-reported preoperative exercise level was used to stratify the study population into 4 groups: none (no reported exercise), sporadic (once a month), moderate (once per week), and intense (more than once per week). Multi-variate logistic regression analyses were used to assess the impact of preoperative exercise frequency on postoperative outcomes, including complications, hospital readmissions and length of stay. Changes in quality of life and pain from baseline to 30-days postoperatively were assessed using the Hernia-Related Quality of Life Survey and National Institutes of Health Patient-Reported Outcomes Measurement Information System 3A Pain Scale.

RESULTS

A total of 2,994 patients were included in the study, out of which 1,519 (50.7%) patients reported no preoperative exercise, 662 (22.1%) sporadic exercise, 467 (15.6%) moderate exercise, and 346 (11.6%) intense exercise. A total of 1,253 patients (19.2%) experienced a postoperative complication, out of which 249 (3.8%) had a surgical site infection. After multi-variable analysis and adjusting for demographics, comorbidities, and hernia characteristics, increasing exercise frequency (versus no reported exercise) was associated with significantly lower odds of experiencing any postoperative complication (sporadic: odds ratio 0.70; P = .008; moderate: odds ratio 0.62, P = .006; intense: odds ratio 0.67, P = .04), as well as lower odds of readmission (sporadic: odds ratio 0.04; moderate: odds ratio 0.40; intense: odds ratio 0.03; P = .01). Exercise level was not associated with length of stay (sporadic: P = .36; moderate: P = .19; intense: P = .95). No significant differences were found in changes in quality of life or pain from baseline to 30-days after surgery (Hernia-Related Quality of Life Survey, P = .24; National Institutes of Health Patient-Reported Outcomes Measurement Information System 3A P = .14).

CONCLUSION

Patients reporting greater exercise frequency before surgery demonstrated decreased risk of complications and readmission after undergoing ventral hernia repair. Increasing preoperative exercise participation through targeted prehabilitation programs may be a viable way for patients to reduce complications associated with VHR and improve their postoperative recovery.