Robotic retromuscular ventral hernia repair and transversus abdominis release: short-term outcomes and risk factors associated with perioperative complications

Robotic retromuscular hernia repair optimizes short-term outcomes in higher risk patients

BACKGROUND

Smoking, obesity, diabetes mellitus, and COPD are known risk factors for surgical site occurrences (SSO) following open ventral hernia repair. However, little evidence exists on whether these factors also significantly impact SSO after robotic hernia repair. This is a particularly important distinction because robotic approaches have been associated with fewer wound complications. Our aim was to examine the impact of smoking, obesity, diabetes mellitus, and COPD on postoperative SSO after robotic retromuscular hernia repair.

METHODS

A retrospective review was conducted of a prospectively maintained database of ventral hernia repairs at three hospitals within our system from October 2019 to July 2022. These included extended totally extraperitoneal (eTEP) and transabdominal approaches along with transversus abdominis release (TAR). Patient demographics, preoperative evaluation, operative details, 30-day follow-up, and patient-reported outcomes were recorded in the Abdominal Core Health Quality Collaborative (ACHQC) database. Patients were grouped according to exposure; smokers vs. non-smokers, obesity (BMI > 40 vs. < 40), and the presence or absence of diabetes mellitus or COPD. The main outcome measure was SSO at one month follow-up. Logistic regression models were used to determine the association between smoking, obesity, diabetes mellitus, and COPD with postoperative SSO.

RESULTS

A total of 81 adult patients were included; mean age was 55 ± 13 years and 41% were women. ASA scores were as follows: 1 (0%), 2 (30%), 3 (64%), and 4 (4%). The prevalence of risk factors were smoking 17%, obesity 16%, diabetes mellitus 28%, and COPD 6%. The overall SSO rate at 30-day follow-up was 12.2%. SSO rates for obese vs. non-obese patients were 15.4% vs. 11.5%, respectively (p = 0.7). For smokers, the rate of SSO compared to non-smokers was 11.1% vs. 13.3% (p = 0.5). Logistic regression models showed that obesity (OR 0.75, 95% CI 0.13, 4.31; p = 0.7), diabetes (OR 2.04, 95% CI 0.36, 11.7; p = 0.4), smoking (OR 2.55, 95% CI 0.27, 23.9; p = 0.4), and COPD (OR 0.32, 95% CI 0.03, 3.93; p = 0.4) were not predictive of postoperative SSO.

CONCLUSION

In our study, smoking, obesity, diabetes mellitus, and COPD did not predict 30-day follow-up wound complications after robotic retromuscular hernia repair. Given these findings, patients who are unable to optimize these risk factors may still be offered robotic retromuscular repair without increasing risk of postoperative SSO.

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.

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.

Sequential surgeries following transversus abdominis release for abdominal wall reconstruction: Insights from a single-center analysis

INTRODUCTION

Abdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. Despite the popularity of the TAR procedure, current literature regarding post-AWR surgeries is limited. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind.

METHODS

Adult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence.

RESULTS

A total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% of the patients required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17-30 months, resulting in a 36.1% recurrent hernia diagnosis rate.

CONCLUSIONS

Abdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases.

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.

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.

Modifiable comorbidities impact on ventral hernia recurrence following robotic abdominal wall reconstruction using resorbable biosynthetic mesh: 36-month follow-up

Background

There is an ongoing debate on the role of comorbidities in hernia outcomes, particularly with minimally invasive approaches. This study evaluated the impact of modifiable comorbidities (MCMs) on 36-month hernia recurrence rates after robotic transversus abdominis release (TAR) with resorbable biosynthetic mesh underlay for primary ventral hernia repair.

Methods

A review of medical records for patients who underwent the robotic TAR procedure between January 2015 and May 2022 performed by a single surgeon was conducted. Patients were separated into three groups: those with 0, 1, and 2+ MCMs, followed by a breakdown of comorbidity types and combinations of comorbidities. MCMs included obesity, diabetes, and tobacco use. The primary outcomes included hernia recurrence at 36 months and the time between surgery and recurrence.

Results

175 patients met the inclusion criteria, with a mean hernia diameter of 12.9 ± 5.4 cm and a mean BMI of 34 ± 8 kg/m2. 9.7 % of patients experienced hernia recurrence at 36-month follow-up. No significant difference in the recurrence rate and length of time between surgery and recurrence was observed between the groups (p = .265 and p = .283, respectively). No group, single comorbidity, or a combination of comorbidities was found to have significantly increased odds of recurrence at 36 months.

Conclusion

The presence of MCMs, either alone or in combination with another, did not significantly increase the odds of hernia recurrence at 36 months following ventral hernia repair using this approach. Future studies with larger sample sizes and multiple surgeons are needed to corroborate this data.

Key message

Modifiable comorbidities have previously been shown to increase the risk of hernia recurrence after ventral hernia repair. Our study found relatively low rates of hernia recurrence and no significantly increased odds of recurrence among different comorbid groups at 36-month follow-up following robotic transversus abdominis release with resorbable biosynthetic mesh underlay.

EVOLUTION OF COMPONENT SEPARATION TECHNIQUE (REVIEW)

The problem of treatment of incisional ventral hernias is currently very relevant. The appearance of a hernial defect in the area of a previous operation is one of the most frequent long-term complications of any surgical treatment. Component separation techniques are the most modern and promising methods for the treatment of large ventral hernias. The review focuses on the main stages in the development of separation technique, as well as the results of treating patients with incisional ventral hernias using various options for posterior separation repair, which are currently frequently used. It has been established that posterior component separation is an effective and safe method of treatment, however, there is currently insufficient data on the long-term postoperative period and patients quality of life.

Robotic versus hybrid assisted ventral hernia repair: a prospective one-year comparative study of clinical outcomes

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) may be associated with chronic pain, seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence and poor quality of life (QoL). Our study evaluates whether robotic-assisted ventral hernia repair (rVHR) diminishes these complications compared to LVHR with primary closure of the defect (hybrid).

METHODS

Thirty-eight consecutive patients undergoing incisional ventral hernia operation with fascial defect size from 3 to 6 cm were recruited between November 2019 and October 2020. Nineteen patients underwent rVHR and nineteen underwent hybrid operation. The main outcome measure was postoperative pain, evaluated with a visual analogue scale (VAS: 0-10) at 1-month and at 1-year. Hernia recurrence was evaluated with ultrasound examination and QoL using the generic SF-36 short form questionnaire.

RESULTS

At the 1-month control visit, VAS scores were significantly lower in the rVHR group; 2.5 in the hybrid group and 0.3 in the rVHR group (p < 0.001). At the 1-year control, the difference in VAS scores was still significant, 2.8 vs 0.1 (p = 0.023). There was one hernia recurrence in the hybrid group (p = 0.331). QoL did not differ significantly between the study groups when compared to preoperative physical status at 1-year follow-up (p = 0.121). However, emotional status (p = 0.049) and social functioning (p = 0.039) improved significantly in the rVHR group.

CONCLUSIONS

Robotic-assisted ventral hernia repair (rVHR) was less painful compared to hybrid repair at 1-month and at 1-year follow-up. In addition, improvement in social functioning status was reported with rVHR.

TRIAL REGISTRATION ID

5200658.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A comparison of outcomes between class-II and class-III obese patients undergoing robotic ventral hernia repair: a multicenter study

BACKGROUND

Morbid obesity has been considered a contraindication to ventral hernia repair (VHR) in the past. However, the relationship between a greater body mass index (BMI) and adverse outcomes has yet to be established in the minimally invasive sphere, particularly with robotics, which may offer an effective surgical option in these high-risk patients. We sought to investigate this relationship by comparing the outcomes of class-II (BMI: 35-39.9 kg/m²) and class-III (BMI: ≥ 40 kg/m²) obese patients after robotic VHR (RVHR).

METHODS

Data were analyzed from two centers and six surgeons who performed RVHR between 2013 and 2020. Patients with a BMI > 35 kg/m² were included in the study. A 1:1 propensity score match (PSM) analysis was conducted to obtain balanced groups and univariate analyses were conducted to compare the two groups across preoperative, intraoperative, and post-operative timeframes. Postoperative complications and morbidity were reported according to the Clavien-Dindo Classification and comprehensive complication index (CCI^®) systems.

RESULTS

From an initial cohort of 815 patients, 228 patients with a mean BMI of 39.7 kg/m² were included in the study. PSM analysis stratified these into 69 patients for each of the class-II and class-III groups. When comparing matched groups, there were no differences in any of the variables across all timeframes, except for a higher rate of Polytetrafluoroethylene (PTFE)-based mesh use in the class-III group (39.1% vs 17.4%, p = 0.008). The estimated recurrence-free time was 76.4 months (95% CI = 72.5-80.4) for the class-II group and 80.4 months (95% CI = 78-82.8) for the class-III group.

CONCLUSION

This multicenter study showed no difference in outcomes after RVHR between matched class-II and class-III obese patients.

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.

Excess Body Weight and Abdominal Hernia

Background

Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI.

Summary

This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young.

Key Messages

Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

Outcomes of redo-transversus abdominis release for abdominal wall reconstruction

BACKGROUND

Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR.

STUDY DESIGN

Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life.

RESULTS

Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m². Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median  - 9.5).

CONCLUSION

Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures.

A cost analysis of two- versus three-instrument robotic-assisted inguinal hernia repair with mesh: time is money

Equipment expenses and operating times can lead to higher costs with robotic surgery. We compared the cost-effectiveness of 2- vs. 3-instrument (2i vs. 3i) approach to robotic transabdominal preperitoneal inguinal hernia repair. We conducted a retrospective study of 172 patients, with 86 patients in each group. Procedure cost, operative time, morbidity, length of stay, readmission rate, and hernia recurrence at 90 days were compared. Statistical significance was assigned to p < 0.05. No significant differences in preoperative variables nor in postoperative outcomes were identified. Mean operative time was 6 min longer in the 2i group and this approach cost $300 less. The 2i approach was cost-effective for operating room (OR) costs of less than $50 per minute. Surgeon efficiency and OR dollar-per-minute value influence the potential for cost savings with fewer instruments in robotic herniorrhaphy. There is no difference in outcomes when fewer instruments are used.

Robot-assisted Treatment of Epigastric Hernias With a Suprapubic Approach

BACKGROUND

Robot-assisted ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are placed laterally to meet the distance from the fascial defect. The aim of our study is to report our experience of epigastric hernia treatment with trocar insertion in the suprapubic region.

MATERIALS AND METHODS

On a prospectively collected dataset on robot-assisted surgery, patients treated for epigastric hernias with suprapubic approach were identified. Demographic and clinical data were collected and analyzed.

RESULTS

Twelve patients were selected. Median age was 58.5 years [interquartile range (IQR): 47.8 to 67.3 y]; 4 patients were male (33.3%) and the median body mass index was 23.9 kg/m2 (IQR: 22.3 to 26.2 kg/m2). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR: 13.75 to 31.0 mm); median larger mesh diameter was 13.5 cm (IQR: 9.5 to 15.0 cm); and median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication or conversion to open surgery occurred. Postoperatively, 2 patients presented a seroma and median length of hospital stay was 2.0 days (IQR: 1.75 to 3 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 4 to 29 mo).

CONCLUSIONS

In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.

Comparison of Midterm Outcomes Between Open and Robotic Emergent Ventral Hernia Repair

Background. There are no studies on the role of robotics in emergency ventral hernia repair (EVHR). We aimed to compare outcomes of robotic EVHR (REVHR) and open (OEVHR). Methods. We performed a retrospective study of EVHRs performed between 2013 and 2019. Patients who underwent ventral hernia repair in an elective setting and patients who had concomitant non-abdominal wall procedures were excluded. Pre-, intra-, and postoperative variables were compared. Univariate and multivariate analyses were performed. Results. In all, 43 patients underwent OEVHR as compared to 35 patients who underwent REVHR. The patients in both groups were similar in terms of hernia etiology as well as Acute Physiology and Chronic Health Evaluation (APACHE-II) and the Sequential Organ Failure Assessment (SOFA) scores. Mean operative times for the robotic group were almost 2-fold compared with those of the open group (139 minutes vs 70 minutes, respectively; P < .001). Median length of stay (LOS) did not differ between the groups (3 days for both groups; P = .488). Major complications (P = .001), morbidity scores (P = .006), surgical site events (SSEs) (P = .045), and procedural interventions (P = .020) were found higher in the open group. No differences in freedom of recurrence were found (P = .662). Multivariate logistic regression analysis showed that open repair was associated with a 4-fold risk for the development of complications as compared to robotic repair (P = .025; odds ratio (OR) = 4, 95% confidence interval (CI) = 1.193-13.444). Conclusion. Compared to OEVHR, REVHR resulted in longer operative times and lower morbidity, including SSEs and related interventions. However, neither LOS nor recurrence differed between the groups.

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.

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.

Perioperative and midterm outcomes of emergent robotic repair of incarcerated ventral and incisional hernia

The literature surrounding emergent robotic ventral hernia repair (RVHR) is scarce. We aimed to present the results of 6 years of experience of RVHR in the emergency setting. Data were retrospectively analyzed from patients who underwent RVHR in an emergent setting between 2013 and 2019. Complications were assessed with the Clavien-Dindo (CD) and Comprehensive Complication Index (CCI^®) scoring systems. Kaplan-Meier's time-to-event analysis was performed to calculate freedom-of-recurrence. Out of 589 patients who underwent RVHR, 34 patients were included. Median APACHE-II scores were 6.5. The average skin-to-skin time was 139 min. 7/34(20.5%) patients experienced minor complications (CD-grades I-II) and 4/34 (11.7%) patients experienced major complications (CD-grades III-IV). CCI^® scores ranged from 0-42.4. Only one (2.9%) patient experienced hernia recurrence. The mean postoperative follow-up was 20.5 (range 1.6-56.3) months. Emergent RVHR showed promising results in terms of midterm outcomes and overall feasibility. RVHR appears to be effective in emergency settings, however, further multicenter studies with long-term follow-up are needed.

Transabdominal (TA) versus totally extraperitoneal (TEP) robotic retromuscular ventral hernia repair: a propensity score matching analysis

PURPOSE

Retromuscular mesh placement positioning utilizing the robotic platform can be performed using either a transabdominal or an extraperitoneal approach. The aim of this study is to compare short-term outcomes of robotic transabdominal access retromuscular (rTA-RM) repair and robotic totally extraperitoneal access retromuscular (rTEP-RM) repair for ventral hernias METHODS: Patients who underwent robotic retromuscular repair between February 2013-October 2019 were included in the study. A one-to-one propensity score matching (PSM) analysis was conducted to obtain two balanced groups. A comparative analysis was performed in terms of perioperative and early post-operative outcomes.

RESULTS

A total of 214 patients were included for PSM analysis. 82 patients were allocated into each study group. Operative times were longer in rTA-RM group. Adhesiolysis was more frequently required in the rTA-RM group. Intra-operative complications occurred more frequently in patients who underwent rTA-RM repair (p = 0.120; 4.9% in rTA-RM vs. 0% in rTEP-RM). The rate of major complications during the first 90 days did not differ between groups (p = 0.277; 7.3% vs. 2.4%, respectively). The proportion of patients with minor perioperative complications was statistically higher in the rTA-RM group than the rTEP-RM group (p = 0.003; 30.5% vs. 11%, respectively). Overall rate of surgical site events was higher in the rTA-RM group than the rTEP-RM group (p = 0.049; 17.1% vs. 6.1%, respectively). Seroma frequency was higher after rTA-RM repair (p = 0.047; 13.4% vs. 3.7%).

CONCLUSION

Our data suggest that rTEP-RM repair was associated with shorter surgery duration and improved early post-operative outcomes in comparison with rTA-RM repair.

Are elderly patients at high risk for postoperative complications after robotic ventral hernia repair? A propensity score matching analysis

BACKGROUND

The purpose of this study was to compare the elderly (≥65 years) and non-elderly groups regarding perioperative outcomes after robotic ventral hernia repair (RVHR).

METHODS

A one-to-one propensity score matching (PSM) analysis was conducted to obtain balanced groups. Postoperative complications including surgical site events (SSEs) (surgical site infections [SSIs], surgical site occurrences [SSOs], and surgical site occurrence procedural interventions [SSOPIs]) were compared.

RESULTS

The unmatched sample included 521 patients. Of these, 139 patients were elderly (range 65-94 years). After PSM, 98 patients were assigned to each group. Intraoperative variables were similar. The non-elderly and elderly groups experienced similar complication rates during the first 90 days. SSEs (SSIs, SSOs, and SSOPIs) did not differ between the two groups.

CONCLUSION

RVHR is safe and efficacious for patients aged 65 and over. Age alone need not be a prohibitive factor in determining patient selection for RVHR; however, it would be more beneficial to take into consideration other patient-related factors as well.

Minimally invasive component separation technique for large ventral hernia: which is the best choice? A systematic literature review

BACKGROUND

Aim of the present systematic review is to compare the postoperative outcomes after minimally invasive anterior and posterior component separation technique (CST), in terms of postoperative morbidity and recurrence rates.

METHODS

Nine-hundred and fifty-nine articles were identified through Pubmed database. Of these, 444 were eliminated because were duplicates between the searches. Of the remaining 515 articles, 414 were excluded after screening title and abstract. One hundred and one articles were fully analysed, and 73 articles were further excluded, finally including 28 articles. Based on the surgical technique, three groups were created: Group A, endoscopic anterior CST and closure of the abdominal midline by laparotomy; Group B, endoscopic anterior CST and closure of the abdominal midline laparoscopically or robotically; Group C, laparoscopic or robotic posterior CST with transversus abdominal muscle release (TAR).

RESULTS

In group A, B and C, 196, 120 and 236 patients were included, respectively. Surgical and medical complication rates for the three groups were 31.2% and 13.7% in group A, 15.8% and 4.1% in group B, and 17.8% and 25.4% in group C, while recurrence rate was 10.7%, 6.6% and 0.4%, respectively. Statistically significant differences were observed in terms of surgical postoperative complication rate between group A versus B (p = 0.0022) and between group A versus C (p = 0.0015) and of recurrence rate between group A versus C (p = < 0.0001) and B versus C (p = 0.0009).

CONCLUSIONS

Anterior CST with midline closure by laparotomy showed the worst results in terms of postoperative surgical complications and recurrence in comparison to the pure minimally anterior and posterior CST. Posterior CST-TAR showed lowest hospital stay and recurrence rate, although the follow-up is short. However, due to the poor quality of most of the studies, further prospective studies and randomized control trials, with wider sample size and longer follow-up are required to demonstrate which is the best surgical option.

Propensity score matching analysis of short-term outcomes in robotic ventral hernia repair for patients with a body mass index above and below 35 kg/m2

OBJECTIVE

The purpose of this study was to compare perioperative complications after robotic ventral hernia repair between patients with non-obese, class-I obesity with those with class-II or class-III obesity.

BACKGROUND

Obesity is a growing epidemic and is considered as an independent risk factor for a multitude of perioperative complications. Laparoscopic ventral hernia repair has been shown as a safe and feasible approach in population with elevated body mass index (BMI). This study compared overall perioperative complications and surgical site events (SSEs) after robotic ventral hernia repair (RVHR) between patients with a BMI 35 kg/m² or more and patients with a BMI lower than 35 kg/m².

METHODS

A retrospective cohort analysis was conducted with one-to-one propensity score matching (PSM) method to obtain balanced groups evaluating patients who underwent RVHR between February 2012 and June 2019 in a single institution. Preoperative, intraoperative, and postoperative variables were reviewed. Postoperative complications and morbidity were assessed using the Clavien-Dindo classification and comprehensive complication index (CCI^®) score system. SSEs were compared.

RESULTS

Our unmatched sample included 526 patients with an average BMI of 31.2 kg/m². Of these, 29.8% (n = 160) patients were in high-BMI group (range 35-59.2). After PSM, 142 patients were assigned to each group. Both groups experienced similar complication rates during 90 days. Clavien-Dindo grades, CCI^® scores, and SSEs did not differ between the two groups.

CONCLUSION

RVHR in class-II and class-III obese patients is safe, feasible, and effective. In addition to this, it has comparable short-term outcomes with those non-obese and class-I obese patients.

Lateral approach totally extraperitoneal (TEP) robotic retromuscular ventral hernia repair

BACKGROUND

The enhanced (or extended) view total extraperitoneal (TEP) access that was initially described for laparoscopic inguinal hernia repair has been applied to first laparoscopic and now robotic retromuscular ventral hernia repair (RRVHR). However, a 'dynamic' port setup that is based on the area of interest is preferred by most surgeons. In this study, we present our center's early operative outcomes after utilizing a lateral approach TEP-access RRVHR with and without transversus abdominis release (TAR).

METHOD

An evaluation of a prospectively maintained database of hernia patients was conducted identifying patients who underwent a lateral approach TEP-access RRVHR between February 2013 and April 2019. The lateral approach TEP-access RRVHR was described. Patient demographics, intraoperative and postoperative variables were reviewed. Preoperative and postoperative results were presented according to recommended classification systems by European Hernia Society.

RESULTS

Fifty-two patients who underwent a lateral approach TEP-access RRVHR were included in this study. A lateral dock setup was utilized for all patient who had a midline defect, as well as a lateral defect. The mean console time was 121.6 min., skin-to-skin time was 138.5 min. There was no intraoperative complication or conversion. The mean hospital length of stay was 0.71 day. During the mean 6.5 months follow-up period, no hernia recurrence arose.

CONCLUSION

The lateral approach TEP-access RRVHR with and without TAR is a reproducible technique. Feasibility of this approach needs to be demonstrated by other surgeons familiar with retromuscular hernia repair in addition to long-term follow up.