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

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.

Laparoscopic Versus Robotic Ventral Hernia Repair - An ACHQC Database 5-Year Analysis

Introduction

To compare laparoscopic and ventral hernia repair (VHR) in the last 5 years in the United States utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database.

Materials and Methods

A retrospective review of prospectively collected data from the ACHQC database was performed to include all adult patients that underwent laparoscopic and robotic VHR in the last 5 years. Univariate analysis was performed to compare outcomes from laparoscopic and robotic-assisted approaches across perioperative and postoperative outcomes.

Results

ACHQC database identified 11,096 patients with midline hernias who underwent VHR with mesh. The Laparoscopic group with patients from 2018 to 2023 (LAP) had 2,063 patients, and the robotic group (ROBO) had 9,033 patients. There was no difference in sex, age, BMI, DM, smoking status and COPD between groups. Median hernia width was 4 cm (IQR 2-6) in the ROBO group and 3 cm (IQR 2-5) in the LAP group (p < 0.001). Incisional hernia was higher in the ROBO group 5,259 (58%) versus 1,099 (53%) in the LAP group (p < 0.001). Recurrent hernia was more common in the ROBO group when compared with the LAP group (p < 0.001). Both groups had more permanent synthetic mesh. Retromuscular repair was higher in the ROBO group, 3,201 (37.6%) versus 68 (4.2%) in the LAP group (p < 0.001). The intraperitoneal repair was higher in the LAP group 1,363 (83%) versus 2,925 (34%) in the ROBO group (p < 0.001) Transversus Abdominis Release (TAR) was higher in the ROBO group 1,314 (14.5%) versus 5 (0.2%) in the LAP group (p < 0.001). Fascial closure was higher in the ROBO group (8,649; 96.5% versus 1,359; 67.3% in the LAP group p < 0.001). Regarding mesh fixation, regular suture was higher in the ROBO group 92% versus 61% in the LAP group (p < 0.001). Tacks (p < 0.001) was higher in the LAP group. The ROBO group had more patients with an operative time of 240+ minutes when compared with the LAP group (p < 0.001). There was no difference in 30-days readmission rates, recurrence, reoperation, overall postoperative complications, 30-day SSI, SSO, seroma and SSOPI between the groups.

Conclusion

The Robotic approach was associated with more technically challenging ventral hernia repairs with low complication rates over time. However, no differences in postoperative complications were found between the groups.

Robotic versus open ventral hernia repair (ROVHR): a randomized controlled trial protocol

BACKGROUND

Robotic retromuscular hernia repair has proven to be feasible and safe but lacks randomized data to demonstrate significant clinical benefit. The majority of current comparative studies published have been case series, retrospective studies, systematic reviews, or large registry data, all of which have significant limitations and bias (Bittner et al. in Surg Endosc 32:727-734. https://doi.org/10.1007/s00464-017-5729-0 , 2018; Bracale et al in Hernia 25:1471-1480. https://doi.org/10.1007/s10029-021-02487-5 , 2021; Carbonell in Ann Surg 267:210-217. https://doi.org/10.1097/SLA.0000000000002244 , 2018; (Warren et al. in Surg Endosc. https://doi.org/10.1007/s00464-024-11202-1 , 2024; Dewulf et al in BJS Open 6:zrac057. https://doi.org/10.1093/bjsopen/zrac057 , 2022; Maskal and Beffa in Surg Clin N Am 103:977-991. https://doi.org/10.1016/j.suc.2023.04.007 , 2023). It was only recently that the first randomized trial was conducted by Warren et al. comparing open and robotic retromuscular hernia repairs with synthetic mesh (Warren et al. in Surg Endosc. https://doi.org/10.1007/s00464-024-11202-1 , 2024). The data currently available has yielded inconsistent outcomes leaving significant knowledge gaps for clinical decision making. Reduced length of stay for robotic retromuscular repairs has been a consistently proven outcome, however, and therefore, we hypothesized that robotic retromuscular hernia repairs would be superior to open retromuscular hernia repair by reducing length of stay in the hospital by 24 h (Carbonell in Ann Surg 267:210-217. https://doi.org/10.1097/SLA.0000000000002244 , 2018).

METHODS

The Institutional Review Board at all participating sites has approved this protocol. This trial has been registered on clinicaltrials.gov (NCT: 05472987). The ROVHR trial is a registry-based, multicenter, double-blinded randomized trial. The primary hypothesis is robotic retromuscular hernia repairs is superior to open retromuscular hernia repairs by reducing length of stay by at least 24 h. Secondary outcomes include 30-day wound morbidity, readmissions, opioids prescribed and consumed, NRS-11 pain scores obtained daily for the 5 first days after surgery, PROMIS-3a Pain Intensity survey, and patient reported outcomes including Hernia-Related Quality of Life (HerQLes), and EuraHS. Additionally, direct operating room costs will be compared.

DISCUSSION

Based existing literature, we designed a randomized trial with a primary endpoint to determine if robotic retromuscular hernia repairs reduce length of in hospital stay by at least 24 h compared to open retromuscular hernia repairs. This study will add high-level of evidence providing evidence-based outcomes for clinical decision making.

TRIAL REGISTRATION

NCT05472987. Registered on July 20, 2022.

The Clinical Impact of the Introduction of a Robot-Assisted Program in a Specialized Hernia Center: A Propensity Score Matched Cohort Study on Short-Term Outcomes

BACKGROUND

The role of robot-assisted approach in hernia surgery remains controversial due to high procedural costs and the proposed equal outcomes compared with open surgery. In this study, we report the 30-day results of the introduction of robot-assisted approach in a specialized regional ventral hernia repair center.

METHODS

This was a retrospective single-center cohort study including patients undergoing either robot-assisted or open ventral hernia repair from 2017 to 2022. Patients undergoing either approach were matched by propensity scores in a 1:2 ratio on the variables age, type of hernia (primary/incisional), and horizontal fascial defect size to reduce bias risk. Multivariable logistic regression on outcomes length of stay, reoperation, and readmission was performed.

RESULTS

A total of 109 patients undergoing robot-assisted repair were compared to 229 undergoing open repair. Overall, 61.2% were patients had incisional hernia. Mean hernia defect size was 4.9 × 6.5 cm (horizontal × vertical). The mean length of stay was shorter after robot-assisted repair (0.1 vs. 1.9 days, p < 0.001) as was the incidence of readmission (3.7% vs. 17.0%, p < 0.001). The incidence of reoperation was tangentially significantly lower after robot-assisted repair (0.9% vs. 6.6%, p = 0.045); however, the estimate was significant after adjusting for confounders (OR 0.11, CI 0.01-0.89, p = 0.038).

CONCLUSIONS

Length of stay and readmission rates were significantly decreased after the introduction of a robot-assisted approach for ventral hernia repair.

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.

Comparing Open and Robotic Unilateral Transversus Abdominis Release in Incisional Hernias With a Lateral Component: A Single Center Retrospective Study

Introduction

Lateral hernias are often more challenging to correct when compared to midline defects, due to the anatomic boundaries of the bony pelvis, retroperitoneum, and costal margin. With the insurgence of robot assisted abdominal wall surgery, these defects have been found more manageable through a minimal invasive repair. In this study, we aim to present our short-term results of incisional hernia repair with a lateral component requiring a unilateral transversus abdominis release, through open surgery versus robot assisted.

Methods

A retrospective analysis was performed of our robotic and open abdominal wall repairs of lateral hernias, where a unilateral transversus abdominis release was performed, between January 2017 and December 2023. Patient, hernia and perioperative details are reported.

Results

54 patients in the open group versus 10 patients in the robotic group were included. Hernia width and hernia surface area were higher in the open group, but not significant. Operation time was similar between open and robotic procedures. In-hospital complications, surgical site infection and clinical seroma rate during the first 30 postoperative days were similar in both groups. There was a clear difference in length of stay, in favor of the robotic group.

Discussion

In our limited series, a robotic approach seems safe and feasible when faced with large lateral hernias. Short-term results show a shorter length of stay using the robotic approach, with no significant difference in short term complications, specifically SSI-rate. However, conclusions are limited due to the low number of patients and additional studies should be performed to account for long term recurrence and increase included patient number.

Long-term patient reported outcomes after robotic, laparoscopic, and open ventral hernia repair

INTRODUCTION

Current evidence demonstrates questionable incremental benefit of robotic abdominal wall (ventral) hernia repair when compared to other approaches. However, data are mainly limited to 30-day outcomes and do not capture long-term patient reported outcomes (PROs) where the robotic may provide distinct advantages.

METHODS

We analyzed patients who underwent ventral hernia repair from January 2020-September 30, 2022 in the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR). Validated PROs included the Ventral Hernia Recurrence Inventory (VHRI), PROMIS Pain Intensity 3a (Pain 3a), and HerQLes quality of life measures. Survey weighting was employed to reduce non-response bias and balance respondents with the overall COHR population. Logistic regression was used to assess the relationship of operative approach with answering "Yes" to the 3 VHRI questions, reporting a worse than average Pain 3a score, and reporting a below median HerQLes score. Models accounted for patient, hernia, and operative characteristics.

RESULTS

Our sample included 1583 patients undergoing hernia repair, of which 507 (32.0%) were robotic, 202 (12.8%) were laparoscopic, and 874 (55.2%) were open. Median follow up time was 1.3 years (IQR 1.2-1.5). Patient characteristics were similar across approaches. Robotic repairs were more often performed electively, on larger hernias, and with mesh. After controlling for covariates, a robotic approach was associated with a lower predicted probability of reporting a bulge [19.5% (95% CI 15.7-23.2%)] than a laparoscopic approach [26.8% (95% CI 20.4-33.2%)], but was no different than an open approach [18.8% (95% CI 16.1-21.6%)]. No other differences in PROs were found by approach.

CONCLUSIONS

We found a lower likelihood of reporting a bulge after robotic ventral hernia repair when compared with a laparoscopic approach, but no difference when compared with an open approach. No other differences in long-term PROs were found when comparing robotic to laparoscopic or open approaches.

[Planned Ventral Hernia After Open Abdomen Therapy: Complex Incisional Hernia Repair]

A planned ventral hernia after open abdomen therapy is a rare hernia entity because the fascial closure rate has been increased due to established concepts for open abdominal treatment. Nevertheless, fascial closure is not always successful, and a planned ventral hernia has to be treated later. Preoperative optimisation and planning are essential for such challenging abdominal wall repairs.In a single centre retrospective analysis, all incisional hernias from 2013 to 2023 (n = 632) were identified and planned hernias after a laparostomy were selected (n = 11). The data on surgical management were obtained from the patient files for the operation reports. Literature search was conducted with PubMed (Medline).In all cases a physical examination, abdominal sonography, CT abdomen and a colonoscopy were carried out preoperatively. The median size of the abdominal wall defects were horizontally 13 cm (6-35 cm) and vertically 18 cm (10-28 cm). Botulinum toxin A has been used preoperatively since 2018. Median fascial closure was successful intraoperatively in all 11 patients. The surgical techniques included sublay, IPOM, sandwich technique, intraoperative fascial traction, and component separation.Planned ventral hernias after open abdomen treatment should always be considered complex hernias for which the entire expertise in hernia surgery is required. Comprehensive preoperative optimisation with botulinum toxin A infiltration is essential to facilitate anatomically appropriate reconstruction through midline closure with mesh augmentation.

Comparison of open and endoscopic posterior component separation with transversus abdominis release: a propensity score-matched study

BACKGROUND

Posterior component separation with transversus abdominis release (TAR) is considered to be the optimal technique for large incisional ventral hernia repair. Endoscopic TAR (eTAR) that gets all the benefits of minimally invasive surgery (MIS) gives a possibility to enhance results of the treatment. The aim of our study was to make the comparison between open and endoscopic TAR procedures with an emphasis on frequency and severity of postoperative complications in comparable groups.

MATERIALS AND METHODS

All patients had midline incisional hernia and underwent either open (open TAR group) or endoscopic (eTAR group) Rives-Stoppa repair in combination with bilateral transversus abdominis release in Moscow City Hospital №1 from January 2018 to December 2022. A propensity score matching (PSM) was used to make groups comparable. Postoperative complications were classified according to Clavien-Dindo Classification, and Comprehensive complication index was calculated.

RESULTS

We performed 133 open and endoscopic TAR separation for midline incisional hernia. After PSM analysis 51 patients were matched to each group. Overall surgical morbidity in the open TAR group (56.9%) was statistically significantly higher than in the eTAR group (29.4%) (p = 0.009). There were more severe complications (Clavien IIIa-V) in the open TAR group (11.8% vs. 0%, p = 0.027). Length of hospital stay after surgery was shorter in eTAR group (p < 0.001). The Comprehensive complication index in the open TAR group was significantly higher than in eTAR group, 8.7 (0-20.9) vs. 0 (0-8.7) (p = 0.011).

CONCLUSION

Based on the data from our study, the entire MIS procedure including endoscopic TAR is a safe and optimal technique for surgery of midline incisional ventral hernia, requiring TAR separation in terms of reducing the rate of postoperative complications, their severity and hospital length of stay, compared to open TAR procedure.

Minimally Invasive Pauli Parastomal Hernia Repair

BACKGROUND

Although originally described as an open procedure, the application in the setting of minimally invasive surgery of the Pauli technique for parastomal hernia repair is gaining interest among surgeons owing to encouraging early results. We aimed at combining and analyzing the results of minimally invasive Pauli repair by assessing the available evidence.

METHODS

A literature search in Pubmed, Embase, and Web of Science was undertaken to include all articles reporting on minimally invasive repair of parastomal hernias using the Pauli technique.

RESULTS

Data regarding a total of 75 patients across 11 articles published between 2019 and 2023 were included. Patients received surgery either by a laparoscopic (27%) or robotic (73%) approach. A transabdominal route was chosen in 62 patients (83%), while an extraperitoneal technique was employed in the remaining 13 patients. The rate of postoperative morbidity was 34%, with 10% being the incidence of grade >II complications. The reported overall rate of recurrence was 7% at a median follow-up of 1 to 43 months.

CONCLUSIONS

The available evidence derived from a growing number of centers suggests that minimally invasive Pauli repair is a viable option to treat parastomal hernias. Despite robust, high-level data still lacking, preliminary experiences indicate promising results.

Open versus robotic transversus abdominis release for ventral hernia repair: an updated systematic review, meta-analysis, and meta-regression

AIM

Posterior component separation using transversus abdominis release (TAR) is well established as an option for repair of large hernia defects. TAR can be performed robotically (rTAR) or open (oTAR) with limited data to demonstrate benefit and guide decision making. We conducted a systematic review and meta-analysis comparing rTAR and oTAR approaches for ventral hernia repair (VHR).

MATERIAL AND METHODS

We searched Pubmed, Embase, Cochrane, and Web of Science for studies comparing rTAR and oTAR for VHR. Hybrid rTAR was not included in our analysis. Our primary outcomes were overall postoperative and intraoperative complications, surgical site occurrences (SSO), SSO requiring surgical intervention (SSOPI), surgical site infection (SSI) superficial or deep, and fascial closure. Additional outcomes were operative time (OT), readmission, length of hospital stay (LOS). We performed sensitivity analysis to explore reasons for heterogeneity and outliers, and a proportional meta-analysis of conversion during rTAR. We performed a meta-regression exploring the relationship of BMI, hernia defect and mesh width rTAR/oTAR with the analyzed outcome within each study.

RESULTS

503 studies were screened and seven studies were included in this analysis. Our sample totaled 780 patients, of which 298 (38.2%) underwent rTAR. Defect width ranged between 8.7 to 13.5 cm (cm) for rTAR and 10 to 13.5 cm for oTAR. Mean mesh area ranged from 66.9 to 980 cm2 and from 51.3 to 1344 cm2 for rTAR and oTAR respectively. We found lower overall complications (9% versus 24.6%; RR 0.43; 95% CI 0.26 to 0.73; P < 0.01) and intraoperative complication (5.9% versus 9.1%; RR 0.44; 95% CI 0.22 to 0.88; P = 0.02) rates for the rTAR group. There was no difference in fascial closure between the groups (99% versus 94.6%; RR 1.05; 95% CI 0.99 to 1.11; P = 0.11). rTAR presented lower SSI rates (2.5% versus 7.8%; RR 0.33; 95% CI 0.13 to 0.8; P = 0.01). No differences were found in SSO (16.3% versus 13.7%; RR 0.87; 95% CI 0.51 to 1.48; P = 0.6) or SSOPI (5.4% versus 8.9%%; RR 0.5; 95% CI 0.22 to 1.15; P = 0.1) rates. No statistically significant differences were found in superficial SSI (0.76% versus 3%; RR 0.36; 95% CI 0.07 to 1.75; P = 0.21) and deep SSI (0% versus 4.2%; RR 0.23; 95% CI 0.02 to 3.12; P = 0.27). Open surgery presented a lower OT (MD -67.7 min; P < 0.001), but robotic surgery showed a reduced LOS (-3.9 days; 95% CI -4.8 to -3.1; P < 0.001). No differences were found in readmission and 1 year recurrence rates. The proportional meta-analysis showed a conversion to open rate of 6.4 per 100 patients (95% CI 3.3 to 12 patients) during rTAR. Meta-regression presented no statistically significant influences of rTAR/oTAR mesh width and defect width relations and BMI, despite the analysis was limited by the low number of studies.

CONCLUSION

Robotic TAR may be associated with lower intraoperative and postoperative complications, lower SSI, shorter LOS, and longer operative times when compared to oTAR. Given the limitations of the included studies, randomized trials are needed to better evaluate the impact of the robotic-assisted surgery for complex abdominal wall reconstruction.

PROSPERO REGISTRATION

CRD42024540991.

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.

Surgical Approach and Long-Term Recurrence After Ventral Hernia Repair

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposure

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Laparoscopic transversus abdominis release for complex ventral hernia repair: technique and initial findings

PURPOSE

The open Rives-Stoppa retrorectus and transversus abdominis release (TAR) techniques are well established in open ventral and incisional hernia repair. The principles are currently being translated into minimally invasive surgery with different concepts. In this study, we investigate our initial results of transperitoneal laparoscopic TAR for ventral incisional hernia repair (laparoscopic TAR).

METHODS

Over a 20-month period, 23 consecutive patients with incisional hernias underwent surgery. Laparoscopic TAR was performed transperitoneally with adhesiolysis from the anterior abdominal wall, development of the retrorectus space and TAR, midline reconstruction and extraperitoneal mesh reinforcement.

RESULTS

There were 23 incisional hernias, of which 70% were M2-M4 and 60% were W3. Median patient age was 68 years and the median BMI was 31. Median operating time was 313 min, and hospital stay was 4 days. Morbidity was 26% (Clavien-Dindo 1: n = 4 and 2 + 3b: n = 2).

CONCLUSION

With the laparoscopic TAR, it was possible to treat a series of patients with ventral incisional hernias. The operating times were long. However, with a low rate of perioperative complications the hospital stay was short As feasibility is demonstrated, the clinical relevance of the method has to be further evaluated.

Systematic review of robotic ventral hernia repair with meta-analysis

BACKGROUND

Despite being one of the most common operations performed by general surgeons, there is a lack of consensus regarding the recommended approach for ventral hernia repair (VHR). Recent times have seen the rapid development of new techniques, such as robotic ventral hernia repair (RVHR). This systematic review and meta-analysis aims to evaluate the currently available evidence relating to RVHR, in comparison to open VHR (OVHR) and laparoscopic VHR (LVHR).

METHODS

A systematic search of the following databases was conducted: PubMed, Embase, Scopus and Web of Science. A meta-analysis was performed for the outcomes of length of stay (LOS), recurrence, operative time, intraoperative complications, wound complications, 30-day readmission, 30-day reoperation, mortality and costs.

RESULTS

A total of 39 studies met inclusion criteria. Overall, RVHR reduced LOS, intra-operative complications, wound complications and readmission compared to OVHR. Compared to LVHR, RVHR was associated with increased operative time and costs, with comparable clinical outcomes.

CONCLUSION

There is currently a lack of robust evidence to support the robotic approach in VHR. It does not demonstrate major benefits in comparison to LVHR, which is more affordable and accessible. Strong quality, long-term data is required to help with establishing a gold standard approach in VHR.

[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.

Robotic surgery for inguinal and ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis assessed the effectiveness of robotic surgery compared to laparoscopy or open surgery for inguinal (IHR) and ventral (VHR) hernia repair.

METHODS

PubMed and EMBASE were searched up to July 2022. Meta-analyses were performed for postoperative complications, surgical site infections (SSI), seroma/hematoma, hernia recurrence, operating time (OT), intraoperative blood loss, intraoperative bowel injury, conversion to open surgery, length of stay (LOS), mortality, reoperation rate, readmission rate, use of opioids, time to return to work and time to return to normal activities.

RESULTS

Overall, 64 studies were selected and 58 were used for pooled data analyses: 35 studies (227 242 patients) deal with IHR and 32 (158 384 patients) with VHR. Robotic IHR was associated with lower hernia recurrence (OR 0.54; 95%CI 0.29, 0.99; I2: 0%) compared to laparoscopic IHR, and lower use of opioids compared to open IHR (OR 0.46; 95%CI 0.25, 0.84; I2: 55.8%). Robotic VHR was associated with lower bowel injuries (OR 0.59; 95%CI 0.42, 0.85; I2: 0%) and less conversions to open surgery (OR 0.51; 95%CI 0.43, 0.60; I2: 0%) compared to laparoscopy. Compared to open surgery, robotic VHR was associated with lower postoperative complications (OR 0.61; 95%CI 0.39, 0.96; I2: 68%), less SSI (OR 0.47; 95%CI 0.31, 0.72; I2: 0%), less intraoperative blood loss (- 95 mL), shorter LOS (- 3.4 day), and less hospital readmissions (OR 0.66; 95%CI 0.44, 0.99; I2: 24.7%). However, both robotic IHR and VHR were associated with significantly longer OT compared to laparoscopy and open surgery.

CONCLUSION

These results support robotic surgery as a safe, effective, and viable alternative for IHR and VHR as it can brings several intraoperative and postoperative advantages over laparoscopy and open surgery.

The Role of Robotics in Abdominal Wall Reconstruction

Robotic abdominal wall reconstruction is becoming an accepted technique to approach complex hernias in a minimally invasive fashion. There remain a deficit of high-quality data to suggest significant clinical benefit but current randomized trials are ongoing. Robotic surgery can be applied to a range of abdominal wall defects safely and with positive outcomes which are at least equivocal to open abdominal wall techniques.

Laparoscopic Ventral Hernia Repair

The laparoscopic approach to ventral hernia repair is a safe and effective approach for both elective and emergent repair. The preoperative technical considerations include assessment of incarceration and potential for extensive adhesiolysis, size of defect, and atypical hernia locations. Preoperative considerations include weight loss and lifestyle modification. There are multiple methods of fascial defect closure and mesh fixation that the surgeon may consider via a laparoscopic approach, making it adaptable to varying clinical scenarios and anatomic challenges. Compared with open repair laparoscopic repair is associated with reduced surgical wound site infection, and compared with robotic repair outcomes are similar.

One-step totally robotic Hartmann reversal and complex abdominal wall reconstruction with bilateral posterior component separation: a technical note

AIM

This paper describes a robotic approach to combined gastrointestinal continuity restoration and complex abdominal wall reconstruction after Hartmann's procedure complicated by large midline and parastomal hernias.

METHODS

A robotic Hartmann reversal is performed, followed by robotic retromuscular abdominal wall reconstruction of all ventral defects with bilateral posterior component separation using the double-docking approach. Surgical steps are thoroughly described, and the accompanying video highlights critical steps of the procedure, anatomical landmarks and technical details relevant to successful completion.

RESULTS

Complete restoration of the anatomy was achieved with an operative time of 6.5 h. Mobilization occured on day 1, and bowels were opened on day 3. Surgical discharge was possible on day 5. No intra-operative surgical complication occurred and follow-up at 6 months showed no recurrence or mid-term complication.

CONCLUSION

Combined minimally invasive reconstruction of the gastrointestinal tract and abdominal wall was feasible using a robotic system. In addition, potential advantages of postoperative rehabilitation and reduced surgical site complications are suggested. Prospective evaluation of the technique is ongoing.

Description of the Current Da Vinci® Training Pathway for Robotic Abdominal Wall Surgery by the European Hernia Society

Background: Robot assisted laparoscopic abdominal wall surgery (RAWS) has seen a rapid adoption in recent years. The safe introduction of the robot platform in the treatment of abdominal wall hernias is important to safeguard the patient from harm during the learning curve. The scope of this paper is to describe the current European training curriculum in RAWS. Methods and Analysis: The pathway to competence in RAWS will depend on the robot platform, experience in other abdominal procedures (novice to expert) and experience in the abdominal wall repair techniques. An overview of the learning curve effect in the initial case series of several early adopters in RAWS was reviewed. In European centres, current training for surgeons wanting to adopt RAWS is managed by the specific technology-based training organized by the company providing the robot. It consists of four phases where phases I and II are preclinical, while phases III and IV focus on the introduction of the robotic platform into surgical practice. Conclusion: On behalf of the Robotic Surgery Task Force of the European Hernia Society (EHS) we believe that the EHS should play an important role in the clinical phases III and IV training. Courses organized in collaboration with the robot provider on relevant surgical anatomy of the abdominal wall and procedural steps in complex abdominal wall reconstruction like transversus abdominis release are essential. Whereas the robot provider should be responsible for the preclinical phases I and II to gain familiarity in the specific robot platform.