Incidence of acute postoperative robotic port-site hernias: results from a high-volume multispecialty center

Robotic abdominopelvic surgery: a systematic review of cross-platform outcomes

As the global surgical robotic ecosystem diversifies, multi-platform surgery is becoming increasingly common. The natural question is whether these robots differ in performance and cost. We address this question and report the first systematic review comparing platforms. A systematic search identified clinical studies comparing at least two platforms. Of 287 studies, 31 were included, with 5 RCTs and 26 cohort studies, including 3624 patients. All studies compared da Vinci with Hintori, Hugo, KangDuo, Micro-Hand, Revo-I, Senhance, and Versius robots. Comparisons were across specialties: urology (18 studies; upper and lower tract), general surgery (11 studies; inguinal and ventral hernia, cholecystectomy, colorectal, pancreatic, oesophagectomy, distal gastrectomy), gynaecology (3 studies; hysterectomy, sacrocolpopexy). There were no differences in conversion rate, estimated blood loss, complication rate, pathological parameters, oncological outcomes (6 months), and functional outcomes (12 months). Results were mixed on operative time and its components. Length of stay was largely similar. Surgeon task load was similar (2 studies). Operative cost was 45-60% lower on the newer platforms (3 studies). Operative, clinical, oncological, and functional outcomes were similar for da Vinci and the newer robots across a range of abdominopelvic procedures, with a signal of lower cost on newer types. Studies were heterogeneous. Data on non-technical skills, other human factors, and comparative learning curves was scant. The majority of evidence was low quality and retrospective. However, accumulating evidence on safety, efficacy, and non-inferiority of the newer platforms has implications for robotic training programmes and procurement.

Robotics can decrease the rate of post-operative ventral hernia: a single centre retrospective cohort study

Midline incision for extra-corporeal anastomosis is common with traditional laparoscopic right hemicolectomy. Incisional hernias develop in up to 20% of these patients within a year adding considerable morbidity and healthcare costs. Robotic assisted surgery (RAS) improves technical ease of intra-corporeal anastomosis, preventing midline extraction but its benefit over laparoscopy remains debated. We aimed to determine if robotic assisted surgery and Pfannenstiel extraction decreased the rate of radiologically detected incisional hernias compared to standard laparoscopy with extra-corporeal anastomosis. The secondary outcomes aimed to evaluate incidence of port site hernias in 8 mm robotic ports for which routine closure is not followed. Our single centre retrospective cohort study included patients who had minimally invasive right hemicolectomy and had cross-sectional imaging at least 1-year later. Patient demographics, body mass index, history of smoking or previous surgery was recorded. At imaging, evidence of new extraction site or port site-site hernia, contents and clinical impact was noted. A total of 100 patients (50 robotic and 50 laparoscopic) were included. Baseline characteristics appeared equally distributed. 16% (8 patients) who had laparoscopic surgery developed midline extraction site hernias which was significantly higher to RAS group (0 patients). 3 patients developed hernias at the site of robotic ports and this was more commonly at the right iliac fossa port. RAS, by simplifying intra-corporeal anastomosis has potential to eliminate incisional hernias, particularly when Pfannenstiel extraction is used. The potential for 8 mm robotic ports to develop clinically significant hernias cannot be ignored and meticulous closure can prevent patient harm.

A case report and review of the literature of 7-millimeter lateral port-site herniation following total laparoscopic hysterectomy

Port-site herniation (PSH) is a rare complication observed postlaparoscopic surgery, typically associated with port sizes of 10 mm or larger, commonly occurred at umbilicus. While occurrences of extra-umbilicus with port size smaller than 10 mm are rare, we present a case detailing a lateral 7 mm PSH diagnosed on the 8th day following a total laparoscopic hysterectomy. The patient exhibited clinical symptoms indicative of partial small bowel obstruction, which became apparent on the third postoperative day. Computed tomography revealed significant small bowel dilatation and herniation through the previously employed 7 mm trocar site. Notably, this trocar site had been utilized with uterine screw. Prompt laparoscopic repair successfully addressed the herniation. The patient demonstrated satisfactory recovery and was subsequently discharged. While current practice recommends fascial incision closure for port size ≥10 mm. In light of our case, we propose considering fascial closure for small-size trocar subjected to any use of a manipulator.

Robotic approach to colonic resection: For some or for all patients?

The robotic approach is rapidly gaining momentum in colorectal surgery. Its benefits in pelvic surgery have been extensively discussed and are well established amongst those who perform minimally invasive surgery. However, the same cannot be said for the robotic approach for colonic resection, where its role is still debated. Here we aim to provide an extensive debate between selective and absolute use of the robotic approach for colonic resection by combining the thoughts of experts in the field of robotic and minimally invasive colorectal surgery, dissecting all key aspects for a critical view on this exciting new paradigm in colorectal surgery.

An 8-mm port site hernia after robotic-assisted ileocecal resection: a case report

BACKGROUND

Robotic-assisted surgery is steadily becoming more prominent. The majority of reports regarding port site hernias (PSHs) have involved laparoscopic procedures. Currently, it is common to suture the fascia at port sites that are 10 mm or larger; however, the closure of 5-mm port sites is not considered mandatory. The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) utilizes a distinctive 8-mm port. We report a case of an early-onset PSH at an 8-mm port site after robotic-assisted ileocecal resection.

CASE PRESENTATION

A 74-year-old male patient with a body mass index of 19.7 kg/m2 was diagnosed with cecal cancer and underwent robotic-assisted ileocecal resection. A 3-cm midline incision was made at the umbilicus for insufflation. Under laparoscopic visualization, three ports (12 mm, 8 mm, and 8 mm) were inserted in the lower abdomen. An 8-mm port was inserted in the left subcostal region, and a 5-mm port was inserted in the left lateral abdomen. The procedure was performed without significant intraoperative complications. The fascia was closed only at the umbilicus and 12-mm port site; the fascia at the 8-mm port sites was not closed. The patient was initially discharged without complications; however, on postoperative day 11, the patient was urgently hospitalized again because of PSH incarceration. After manual reduction, the fascia was sutured closed under local anesthesia. The hernial defect was small and barely allowed the insertion of a little finger. There was no evidence of compression or significant damage to the fascia. On postoperative day 27, the patient was discharged after experiencing good recovery.

CONCLUSIONS

Robotic-assisted colectomy could contribute to the risk of PSHs because of its surgical characteristics. Although routine closure of the fascia at 8-mm port sites is not mandatory, it may be beneficial in certain cases.

Versius robotic surgical system: case series of 18 robot-assisted radical prostatectomies

OBJECTIVE

To present the results of the first series of patients treated with robot-assisted radical prostatectomy (RARP) with the use of the Versius® Surgical System (CMR Surgical Ltd., Cambridge, UK). RARP has demonstrated better perioperative outcomes compared to open RP. However, RARP remains limited by platform availability and cost-effectiveness issues. The increasing competition from new robotic surgical platforms may further drive utilisation of the robotic approach.

PATIENTS AND METHODS

Data were collected prospectively for our first 18 consecutive patients with localised prostate cancer who underwent RARP at our centre over a 3-month period. We recorded parameters, including patient demographics and perioperative outcomes. We also report our optimised set-up with regard to trocar placement, bedside unit placement, and overall composition of the operating room for this procedure. Describing the incremental modifications carried out to achieve reductions in set-up and operating times to optimise utilisation of the Versius system.

RESULTS

The median (interquartile range [IQR]) set-up time was 8.5 (7-10) min. The median (IQR) console time was 201 (170-242) min. The median (IQR) operative time was 213 (186-266) min. The median (IQR) total surgery time was 226 (201-277) min. Bilateral pelvic lymphadenectomy median (IQR) time was 19 (17-20) min. There were no complications and/or limitations related to the use of the Versius system including need for conversion. There were no relevant intra- or postoperative complications at the 1-month follow-up related to the use of the Versius system. Patients were discharged after a median (IQR) of 4 (3.75-5) days, and the transurethral catheter was removed after a mean (range) of 8 (7-14) days. Continence at 2 months was achieved in 72.2% of the patients.

CONCLUSIONS

Performing RARP using the Versius system is feasible, safe, and easily reproducible. Our set-up enables a rapid docking approach and efficient completion of the surgery.

Thoughts on Trocar Site Hernia Prevention. A Narrative Review

Background: Laparoscopic and robot-assisted surgery is now common place, and each trocar site is a potential incisional hernia site. A number of factors increase the risk of trocar site hernia (TSH) at any given trocar site. The aim of this paper is to explore the literature and identify the patients and the trocar sites at risk, which may allow target prevention strategies to minimise TSH. Methods: A pub med literature review was undertaken using the MeSH terms of "trocar" OR "port-site" AND "hernia." No qualifying criteria were applied to this initial search. All abstracts were reviewed by the two authors to identify papers for full text review to inform this narrative review. Results: 961 abstracts were identified by the search. A reasonable quality systematic review was published in 2012, and 44 additional more recent publications were identified as informative. A number of patient factors, pre-operative, intra-operative and post-operative factors were identified as possibly or likely increasing the risk of TSH. Their careful management alone and more likely in combination may help reduce the incidence of TSH. Conclusion: Clinically symptomatic TSH is uncommon, in relation to the many trocars inserted every day for "keyhole" surgery, although it is a not uncommon hernia to repair in general surgical practice. There are patients inherently at risk of TSH, especially at the umbilical location. It is likely, that a multi-factored approach to surgery, will have a cumulative effect at reducing the overall risk of TSH at any trocar site, including choice of trocar type and size, method of insertion, events during the operation, and decisions around the need for fascial closure and how this is performed following trocar removal.

Reporting and grading of complications for intracorporeal robot-assisted radical cystectomy: an in-depth short-term morbidity assessment using the novel Comprehensive Complication Index®

OBJECTIVE

To assess suitability of Comprehensive Complication Index (CCI^®) vs. Clavien-Dindo classification (CDC) to capture 30-day morbidity after robot-assisted radical cystectomy (RARC).

MATERIALS AND METHODS

A total of 128 patients with bladder cancer (BCa) undergoing intracorporeal RARC with pelvic lymph node dissection between 2015 and 2021 were included in a retrospective bi-institutional study, which adhered to standardized reporting criteria. Thirty-day complications were captured according to a procedure-specific catalog. Each complication was graded by the CDC and the CCI^®. Multivariable linear regression (MVA) was used to identify predictors of higher morbidity.

RESULTS

381 complications were identified in 118 patients (92%). 55 (43%), 43 (34%), and 20 (16%) suffered from CDC grade I-II, IIIa, and ≥ IIIb complications, respectively. 16 (13%), 27 (21%), and 2 patients (1.6%) were reoperated, readmitted, and died within 30 days, respectively. 31 patients (24%) were upgraded to most severe complication (CCI^® ≥ 33.7) when calculating morbidity burden compared to corresponding CDC grade accounting only for the highest complication. In MVA, only age was a positive estimate (0.44; 95% CI = 0.03-0.86; p = 0.04) for increased cumulative morbidity.

CONCLUSION

The CCI^® estimates of 30-day morbidity after RARC were substantially higher compared to CDC alone. These measurements are a prerequisite to tailor patient counseling regarding surgical approach, urinary diversion, and comparability of results between institutions.

Robotic DIEP Patient Selection: Analysis of CT Angiography

BACKGROUND

Preoperative CTA is widely used and extensively studied for planning of DIEP flap breast reconstruction. However, its utility in planning robotic DIEP harvest is undescribed.

METHODS

The authors conducted a retrospective study of consecutive patients presenting to the clinics of select plastic surgeons between 2017 and 2021 for abdominally based autologous breast reconstruction. CTA measurements of intramuscular perforator distance and perforator-to-external iliac distance were used as predicted robotic and open fascial incision lengths, respectively. It was documented if the predicted robotic incision would avoid crossing the arcuate line. Operative notes were reviewed for fascial incision length and number of perforators harvested. Predicted and actual robotic fascial incision lengths were compared.

RESULTS

CTAs were reviewed for 49 patients (98 hemiabdomens). Inadequate or no perforators were identified on CTA in 18% of hemiabdomens. Mean predicted robotic and open DIEP fascial incisions were 3.1 cm and 12.2 cm, respectively, giving robotic approach fascial incision benefit of 9.1 cm (P < 0.001). The predicted robotic incision avoided crossing the arcuate line in 71% of hemiabdomens. Thirteen patients (28%) underwent robotic DIEP harvest. Actual robotic fascial incision length averaged 3.5 cm, which was not significantly different from the mean predicted fascial incision length (P = 0.374). Robotic DIEP flaps had fewer perforators (1.8 versus 2.6, P = 0.058).

CONCLUSION

CTA is useful for identifying patients with anatomy favorable for robotic DIEP flap harvest.

Acute Presentation of Port Site Hernia Following Robot-Assisted Hysterectomy: A Case Report and Review of the Literature

Port site hernia (PSH) has been reported following both laparoscopic and robotic surgery. Subsequent surgical intervention increases postoperative morbidity. We report the case of a PSH through the 8-mm trocar following robot-assisted hysterectomy in a 49-year-old female patient, along with a review of the literature. The case was performed with the standard protocol; however, increased intraoperative bleeding was encountered from right uterine artery and vein. Discharged at 48 h, she presented in emergency on the fourth postoperative day with acute intestinal obstruction. Computed tomography scan showed herniation of the jejunal loop through the 8-mm left-sided port. She underwent resection and anastomosis of the necrosed jejunal loop. We review the literature for PSH following robotic gynecological surgeries. Although rare, PSH requires surgical intervention, increasing the postoperative morbidity. Need for fascial closure of 8 mm ports should be considered. High index of suspicion and early recognition can avoid resection of the bowel loop.