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

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.

Minimally invasive intraperitoneal onlay mesh plus (IPOM +) repair versus enhanced-view totally extraperitoneal (e-TEP) repair for ventral hernias: a systematic review and meta-analysis

INTRODUCTION

Following concerns regarding an intraperitoneal mesh, newer ventral hernia repair (VHR) approaches focus on placing the mesh outside of the peritoneal cavity. The e-TEP technique used the retromuscular space and is suggested to be associated with decreased postoperative pain compared to IPOM +. This study aims to compare the IPOM + with the e-TEP for VHR.

METHODS AND PROCEDURES

We searched for studies comparing endoscopic IPOM + and e-TEP in PubMed, EMBASE, and Cochrane databases from inception until September 2023. Outcomes were Visual Analog Scale (VAS) after 24 h of surgery and between 7 and 10 days after surgery, operative time, length of stay (LOS), seroma, recurrence, and readmission. RStudio was used for statistical analysis. Heterogeneity was assessed with I2 statistics, with random effect for I2 > 25%.

RESULTS

From 149 records, 7 were included, from which 3 were RCTs, 3 were retrospective studies, and 1 was an observational prospective study. 521 patients were included (47% received e-TEP and 53% received IPOM +). 1 study included only robotic surgeries and 6 studies included only laparoscopy. Mean defect width was 3.62 cm ± 0.9 in the e-TEP group and 3.56 cm ± 0.9 in the IPOM + group. IPOM + had higher VAS after 1 day of surgery (MD - 3.35; 95% CI - 6.44; - 0.27; P = 0.033; I2 = 99%) and between 7 and 10 days after surgery (MD - 3.3; 95% CI - 5.33, - 1.28; P = 0.001; I2 = 99%). e-TEP repair showed with longer operative time (MD 52.89 min; 95% CI 29.74-76.05; P < 0.001; I2 = 92%). No differences were seen regarding LOS, seroma, recurrence, and readmission.

CONCLUSION

The e-TEP repair is associated with lower short-term postoperative pain after VHR compared to IPOM +, but with longer operative time. More RCTs are required to assess these results with long-term follow-up and determine its role in the armamentarium of the abdominal wall surgeon.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Laparoendoscopic extraperitoneal surgical techniques for ventral hernias and diastasis recti repair: a systematic review

PURPOSE

this systematic review aims to classify and summarize the characteristics and outcomes of the different laparoendoscopic extraperitoneal approaches for the repair of ventral hernias and diastasis recti described in the last 10 years.

METHODS

a literature search was performed by two reviewers in December 2023 including articles from January 2013, 01 to December 2023, 15. The techniques were selected according to the surgical access site (anterior or posterior to the rectus sheath), the access type (laparoendoscopic, single incision laparoscopic, mini or less open), the main space used to repair the defect (subcutaneous or retromuscular) and the mesh place (onlay, sublay-retromuscular or sublay-preperitoneal) and classified as anterior or posterior approaches.

RESULTS

the literature search retrieved 1755 results and 27 articles were included in the study. The studies included 1874 patients, the mean age ranged from 37.8 to 60.2 years. The access site was anterior in 16 cases and posterior in 11 cases. The mesh was positioned onlay in 13 cases and sublay in 13 cases, with only one study using no mesh. Complications were: seroma, ranging from 0.8 to 81%, followed by skin complications (leak, ischemia, necrosis) from 0.8 to 6.4%, surgical site infections and bleeding. Recurrences ranged from 0% to 12,5%, with a mean follow-up from 1 to 24 months.

CONCLUSION

this systematic review confirms the presence of several new minimally invasive extraperitoneal techniques for the repair of abdominal wall defects, with different advantages and disadvantages. Further studies, with more extensive follow-up data and wider patient groups, are necessary to define specific indications for each technique.

Hybrid intraperitoneal onlay mesh repair for incisional hernias: a systematic review and meta-analysis

INTRODUCTION

Laparoscopic IPOM is technically challenging, especially regarding fascial closure. Hybrid repair has been proposed as a simpler approach. We aimed to compare hybrid and laparoscopic intraperitoneal onlay mesh repair (IPOM) in patients undergoing ventral hernia repair (VHR).

METHODS

We performed a systematic review of Cochrane, Scopus, and MEDLINE databases to identify studies comparing hybrid versus laparoscopic IPOM VHR reporting the outcomes of recurrence, mortality, seroma, postoperative complications, reoperation, surgical site infection, and operative time. Statistical analysis was performed using RStudio 4.1.2 using a random-effects model.

RESULTS

We screened 2,896 articles and fully reviewed 22 of them. A total of five studies, encompassing 664 patients were included. Among them, 337 (50.8%) underwent laparoscopic IPOM. All patients had incisional hernias, with a mean diameter varying from 3 to 12.7 cm, 60% were women, with a mean BMI varying from 29.5 to 38. The hybrid approach had a lower rate of seroma when compared to the laparoscopic (OR 0.22; 95% CI 0.05 to 0.92; p = 0.038; I²=78%). We found no difference in recurrence, mortality, postoperative complications, reoperation, surgical site infection, and operative time between groups.

CONCLUSION

Hybrid IPOM is a safe and effective method for incisional hernia repair. Moreover, it facilitates fascial defect closure and decreases postoperative seromas.

Navigating hernia sac management in minimally invasive inguinal hernia repair: to abandon or to reduce? An updated systematic review and meta-analysis

AIM

Minimally invasive inguinal hernia repair has become increasingly accepted, demonstrating superior outcomes over open procedures in postoperative complications. However, certain postoperative complications, such as seroma, remain a dilemma, with many attributing it to the management of the hernia sac. We aimed to perform a systematic review and meta-analysis comparing the reduction versus abandonment of the hernia sac during laparoscopic inguinal hernia repair.

MATERIAL AND METHODS

Cochrane, Scopus, SciELO, and PubMed were searched for studies comparing reduction and abandonment of the hernia sac. Our primary outcome was seroma. Secondary outcomes were overall complications, postoperative pain, surgical site infection, recurrence, hospital length of stay (LOS), and operative time. We performed a subgroup analysis of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. Statistical analysis was performed with R Studio.

RESULTS

2388 studies were screened, and seven studies were included, comprising 3153 patients, of which 916 (29%) were in the abandonment group. We found higher seroma rates for the abandonment group (RR 1.52; 95% CI 1.22 to 1.89; P < 0.001). No differences were found in overall complications (RR 0.88; 95% CI 0.55 to 1.42; P = 0.61), postoperative pain (RR 1.15; 95% CI 0.46 to 2.87; P = 0.76), recurrence (RR 2.67; 95% CI 0.51 to 14.05; P = 0.25), operative time (MD - 4.45 min; 95% CI - 12.77 to 3.86; P = 0.29), and LOS (MD -0.06 days; 95% CI - 0.14 to 0.02; P = 0.14) between both groups. Subgroup analysis of seroma showed no differences between the groups when analyzing TAPP (19.3% vs. 13%; RR 1.65; 95% CI 0.91 to 2.99; P = 0.1) and TEP (9% vs. 4.3%; RR 1.69; 95% CI 0.62 to 4.6; P = 0.3) procedures.

CONCLUSION

Our systematic review and meta-analysis support that hernia sac abandonment may be associated with increased early seroma rates following laparoscopic inguinal hernia repair, but limited data are available for technique-specific analyses.

Robot-Assisted Extraperitoneal Ventral Hernia Repair-Experience From the First 160 Consecutive Operations With Lateral eTEP and eTAR Techniques

Introduction

There is a growing consensus on the benefits of retro-muscular (RM) mesh positioning, highlighted by its recommendation in the latest edition of EHS guidelines. The eTEP method has facilitated minimally invasive hernia repairs with retro-muscular mesh placement. With the increasing availability of robotic systems, there has been a corresponding increase in robotic adaptations of minimally invasive techniques involving retro-muscular mesh placement.

Materials and Methods

All patients who underwent robotic ventral hernia repair using the lateral extraperitoneal eTEP technique at Kempten Hospital between September 2019 and December 2023 were includes in the study. Preoperative characteristics, perioperative parameters, postoperative parameters, and hernia-specific parameters, were retrospectively analyzed using the hospital information system.

Results

160 patients were operated using a lateral approach eTEP technique during the observation period, 111 (69.38%) for incisional hernia repair and 49 (30.63%) for primary hernia repair. 43 cases required TAR (30 unilateral TAR and 13 bilateral TAR). 139 patients had a medial (86.98%), seven patients (4.14%) a lateral and 14 patients (8.88%) a combined hernia defect. The median operative time was 143 min (range: 53 min-495 min). The median length of hospital stay was 3 days (range: 2-16). There was one intraoperative complication. The postoperative complication rate was 6.25% (10 patients), with 1.72% (2 patients) requiring reoperation. Sonographic follow-up examinations revealed seromas in 5 patients, with 4 located in the retromuscular mesh space and 1 in the former hernia sac. None of these seromas required surgical intervention.

Conclusion

The "lateral approach" of robotic eTEP provides a safe surgical method for treating ventral hernias using minimally invasive techniques and mesh augmentation in the retro-muscular space. Further studies are necessary to compare extraperitoneal with transperitoneal methods.

Transrectus Extraperitoneal Versus Minimally Invasive Inguinal Hernia Repair: A Systematic Review and Meta-Analysis

Purpose: Recent guidelines have recommended minimally invasive surgery (MIS) for unilateral inguinal hernia due to reduced chronic pain. The most performed approaches consist of posterior mesh placement by the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. However, it remains debatable whether the advantage of those techniques stems from the MIS approach or posterior mesh placement or both. As the transrectus preperitoneal (TREPP) technique is an open option for posterior mesh placement, we conducted a systematic review and meta-analysis comparing TREPP and MIS techniques for groin hernia repair. Material and Methods: Cochrane, Embase, Scopus, Scielo, and PubMed were systematically searched for studies comparing TREPP and MIS techniques for groin hernia repair. Outcomes assessed were recurrence, cumulative surgical site occurrences (SSO), surgical site infection (SSI), and postoperative pain. Results: Twenty-nine studies were screened, and eight were thoroughly reviewed. Three studies were included, of which two compared TREPP with the TEP technique, and one compared TREPP with both TEP and TAPP techniques. We found lower SSI rates for the MIS approaches (0.61% versus 0.33%; risk ratios (RRs) 3.96; 95% confidence interval (CI): 1.04-15.16; P = .04). We did not find statistically significant differences regarding recurrence (2.42% versus 2.51%; RR 1.01; P = .98), postoperative pain (4.2% versus 6.4%; RR 0.61; P = .4), and SSO (4.2% versus 4.0%; RR 0.6; P = .43) between TREPP and MIS techniques. Conclusion: Our systematic review and meta-analysis found a lower SSI for the MIS repair but did not find differences regarding recurrence, SSO, and postoperative pain. More studies are required to provide a more accurate conclusion about this topic.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic-assisted surgery for lateral ventral hernias - experience of robot-assisted methods for retromuscular and preperitoneal abdominal wall reconstruction

BACKGROUND

Due to the proximity to bony structures and the complex anatomy of the three-layered lateral abdominal wall, the surgical treatment of lateral ventral hernias is technically demanding. With this study we would like to demonstrate how lateral abdominal wall hernias can be treated using new robotic surgical techniques with extraperitoneal mesh placement.

OBJECTIVES

The purpose of this study is to demonstrate that the application of the robot in minimally invasive treatment of lateral abdominal wall hernias is safe and efficient.

MATERIALS AND METHODS

A retrospective analysis of all patients who underwent robotically-assisted lateral ventral hernia repair surgery from June 2019 to December 2023 was performed.

RESULTS

A total of 50 ventral hernias were operated robotically due to a lateral hernia in the study period. 45 patients had an incisional hernia and 5 patients a primary spighelian hernia. 27 patients had only lateral findings, whereas 23 patients had combined hernias with lateral and medial hernial defects. 18 patients were treated with a preperitoneal mesh (r-vTAPP). 31 patients required TAR to achieve complete fascial closure and sufficient mesh overlap (24 extraperitoneal approach r-eTAR/7 transperitonel approach r-TAR). One patient had to be converted intraoperatively from a planned preperitoneal mesh to an intraperitoneal mesh repair (r-IPOM). The median hernia defect area was 71 cm² (3-375 cm²). The median mesh size was 600 cm² (150-1290 cm²). The median mesh defect ratio (MDR) was 10 (2,33-133,33). Five postoperative complications were encountered (10%). Two reoperations (4%) were required.

CONCLUSION

The utilization of new robotic surgical techniques provides a safe minimally invasive treatment option even for complex lateral ventral hernias that previously posed difficulties in surgical management. The early postoperative results show promising outcomes.

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.

eTEP Rives-Stoppa impact on abdominal contour: a retrospective observational and clinical quality improvement study using Ellipse 9 tool

BACKGROUND

The eTEP Rives-Stoppa (RS) procedure, increasingly used for ventral hernia repair, has raised concerns about postoperative upper abdominal bulging. This study aims to objectively evaluate changes in the abdominal contour after eTEP RS and explore potential causes using a novel analytical tool, the Ellipse 9.

METHODS

Thirty patients undergoing eTEP RS without posterior rectus sheath closure were assessed before and 3 months after surgery using CT scan images. Key measurements analyzed included the distance between linea semilunaris (X2), eccentricity over the Cord (c/a Cord), superior eccentricity (c/a Sup), Y2, and the superior perimeter of the abdomen. The Ellipse 9 tool, which provides graphical images and numerical representations, was utilized alongside patient-reported outcomes to assess perceived abdominal changes.

RESULTS

The study group exhibited a trend toward a flatter abdomen with reduced distance between linea semilunaris(X2). However, 17% of patients developed upper abdominal bulging (5). Significant differences in c/a Cord, c/a Sup, Y2, and the superior perimeter of the abdomen, confirmed with Bonferroni corrections, were noted between bulging (5 patients) and non-bulging groups (25 patients). There was a notable disparity between patient perceptions and objective outcomes.

CONCLUSION

The eTEP RS procedure improved abdominal contour in most patients from a selected cohort. The Ellipse 9 tool was valuable for the objective analysis of these changes. The cause of bulging post-eTEP RS is probably multifactorial. Notably, there was often a discrepancy between patient perceptions of bulging and objective clinical findings.

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.

[Roboticassisted incisional hernia surgery-Retromuscular techniques]

The trend to minimally invasive surgery has also made its way into the surgical treatment of incisional hernias. Unlike other areas of visceral surgery, recent years have seen a resurgence of open sublay repair in incisional hernia procedures, primarily due to the recognition of the retromuscular layer as the optimal mesh placement site. Additionally, with the growing availability of robotic systems in visceral surgery, these procedures are increasingly being offered in the form of minimally invasive procedures. These methods can be categorized based on the access routes: robotic-assisted transperitoneal procedures (e.g., r‑Rives, r‑TARUP, r‑TAR) and total extraperitoneal hernia repair (e.g., r‑eTEP, r‑eTAR). Notably, the introduction of transversus abdominis muscle release enables the robotic-assisted treatment of larger and more complex hernia cases with complete fascial closure. With respect to the comparison with open surgery required in retromuscular hernia treatment, the currently available literature on incisional hernia repair seems to show initial advantages of robotic-assisted surgery in the perioperative course. New technologies create new possibilities. In the context of surgical training the use of surgical robot systems with double consoles opens up completely new perspectives. Furthermore, the robot enables the implementation of models of artificial intelligence and augmented reality and could therefore open up novel dimensions in surgery.

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.