Robotic repair of lateral incisional hernias using intraperitoneal onlay, preperitoneal, and retromuscular mesh placement: a comparison of mid-term results and surgical technique

Transabdominal Preperitoneal (TAPP) versus intraperitoneal onlay Mesh (IPOM) for ventral hernia repair - an updated systematic review and meta-analysis

BACKGROUND

Persistent controversy exists regarding the optimal approach for ventral hernia repair (VHR). Considering the concerns regarding the use of intraperitoneal mesh and the increasing use of robotic technology, transabdominal preperitoneal (TAPP) is increasingly being performed. This study aims to compare TAPP and intraperitoneal onlay mesh (IPOM) for VHR.

METHODS

PubMED, Cochrane, and EMBASE databases were systematically searched from inception to April 2024, for studies on patients undergoing VHR, comparing TAPP and IPOM. Outcomes included were intraoperative complications, such as vascular and bowel injury, and postoperative complications (hernia recurrence within 1 year of operation, seroma, hematoma, ileus, urinary retention, small bowel obstruction). Additional outcomes were hospital length of stay (LOS), operative time, and visual analog scale (VAS) scores after 24 h of surgery.

RESULTS

From 398 records, 8 were included in our pooled analysis, which comprised 7 retrospective cohorts and 1 prospective cohort, totaling 952 patients. 458 (48%) patients underwent laparoscopic VHR and 494 (52%) underwent robotic VHR. Our meta-analysis revealed that TAPP is associated with a lower incidence of overall postoperative complications as a composite outcome (13.9% vs 23.9%; RR 0.66; 95% CI 0.48, 0.92; P = 0.013). After performing a subgroup analysis for robotic surgeries only, we found that TAPP also has a lower rate of urinary retention (RR 0.12; 95% CI 0.02, 0.99; P = 0.049) and hematoma compared to IPOM (RR 0.20; 95% CI 0.04, 0.95; P = 0.043). No differences were seen between both techniques regarding ileus, hernia recurrence, operative time, seroma, small bowel obstruction, vascular injury, and bowel injury. Subgroup analysis for robotic VHR showed similar results. After performing a leave-one-out sensitivity analysis, we also obtained a shorter hospital LOS (MD  - 0.56 days; 95% CI  - 0.86,  - 0.25; p < 0.05) and VAS scores within 24 h of surgery (MD  - 1.04; 95% CI  - 1.61,  - 0.47; p < 0.05) for the TAPP technique.

CONCLUSIONS

IPOM is associated with a higher incidence of hematoma, urinary retention, overall early postoperative complications, and potentially longer hospital LOS and higher VAS pain scores within 24 h compared to TAPP. Therefore, the TAPP should be the technique of choice for minimally invasive VHR when feasible; however, considering the availability of resources and surgeon expertise, IPOM might still be considered a viable alternative.

Incisional hernia repair following pancreatic surgery-open vs laparoscopic approach

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robotic versus open lateral abdominal hernia repair: a multicenter propensity score matched analysis of perioperative and 1-year outcomes

PURPOSE

Lateral abdominal hernias are inherently challenging surgical entities. As such, there has been an increase in the adoption of robotic platforms to approach these challenging hernias. Our study aims to assess and compare outcomes between open (oLAHR) and robotic (rLAHR) lateral abdominal hernia repair using a national hernia-specific database.

METHODS

A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative was performed to include all adult patients who underwent elective lateral hernia repair. A propensity score match analysis was conducted, and univariate analyses were conducted to compare these two surgical modalities across perioperative timeframes.

RESULTS

The database identified 2569 patients. Our analysis matched 665 patients to either the open or robotic groups. The median length of stay, surgical site occurrences (SSO), and surgical site occurrences requiring procedural interventions (SSOPI) were higher in the oLAHR versus the rLAHR group. Overall, oLAHR had a significantly higher rate of having any post-operative complications or any SSO/SSOPI. There was no difference in quality-of-life measures between groups at 30 days and 1 year.

CONCLUSION

Robotic abdominal hernia repair is a safe alternative compared to the open repair of lateral abdominal hernias with better perioperative outcomes. Despite having a longer operative time, the robotic approach can offer a significantly shorter length of stay and an overall lower rate of complications. Ultimately, there is no difference in the quality-of-life measures both at 30 days and 1 year between the open and robotic approaches.

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.