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Perim V, Nogueira R, Kasakewitch JPG, da Silveira CAB, Nguyen DQ, Lima DL, Cavazzola LT, Malcher F. Incisional hernia incidence following laparoscopic versus open abdominal surgery: an updated systematic review and meta-analysis of randomized controlled trials. Hernia 2025; 29:152. [PMID: 40304805 DOI: 10.1007/s10029-025-03347-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2025] [Accepted: 04/14/2025] [Indexed: 05/02/2025]
Abstract
PURPOSE Incisional hernias (IH) are a frequent complication following open surgery (OP). While laparoscopic (LAP) surgery is designed to enhance patient recovery through smaller incisions, contemporary quantitative evidence supporting its efficacy in reducing IH rates (IHR) is sparse. This study aims to provide an overview of IHR following OP and LAP abdominal operations. METHODS We searched for randomized controlled trials (RCTs) studies in PubMed, Cochrane, and Embase from inception until May 2024 comparing OP approach to LAP and reported IH incidence as a postoperative complication. Exclusion criteria included studies involving patients aged ≤ 18 years, those lacking a control group, or those with a follow-up period of less than 12 months. Studies were stratified by procedure type and by fully laparoscopic (T-LAP) versus laparoscopic-assisted (LAP-A) approaches. Statistical analyses were performed using RStudio software. To address potential clinical and methodological heterogeneity across studies, we applied the restricted maximum-likelihood estimator and random-effects models for outcome analysis. RESULTS 8.754 studies were screened, and 72 studies were reviewed. From the initial screening, 28 studies involving 6,113 patients were included, of which 3,337 (54.6%) underwent LAP. Analysis revealed a significantly lower incidence of IH among patients who received LAP (RR 0.51; 95% CI 0.33-0.79). Subgroup analysis by surgery type indicated that bariatric (RR 0.20; 95% CI 0.068-0.578) and fundoplication procedures (RR 0.1; 95%CI 0.018-0.545) were associated with a substantial reduction in IHR. Moreover, totally-laparoscopic (T-LAP) procedures showed a significant reduction in IHR (RR 0.26;95%CI 0.14-0.5), while LAP-A procedures failed to show the same benefit. CONCLUSION LAP surgery is associated with reduced IHR in abdominal operations, with the benefit being particularly notable amongst LAP-A, bariatric, and fundoplication procedures. These findings underscore the advantages of LAP in specific surgical contexts, emphasizing its potential to minimize postoperative complications such as IH. Further research focusing on comparing IHR on open versus LAP approaches is warranted. STUDY REGISTRATION A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024551280).
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Affiliation(s)
- Victor Perim
- Department of Surgery, University of Alabama at Birmingham, 1720 2 Nd Avenue S, Birmingham, AL, 35209, USA
| | - Raquel Nogueira
- Department of Surgery, Montefiore Medical Center, 1825 Eastchester Rd, Bronx, NY, 10461, USA
| | - João P G Kasakewitch
- Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | | | - Diana Q Nguyen
- Department of Surgery, Mount Sinai South Nassau, New York, NY, USA
| | - Diego Laurentino Lima
- Department of Surgery, Montefiore Medical Center, 1825 Eastchester Rd, Bronx, NY, 10461, USA.
| | | | - Flavio Malcher
- System Chief, Abdominal Core Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Takeda Y, Goto K, Kamada T, Abe T, Nakano T, Takano Y, Ohkuma M, Kosuge M, Eto K. Postoperative Pain and Incisional Hernia of Specimen Extraction Sites for Minimally Invasive Rectal Cancer Surgery: Comparison of Periumbilical Midline Incision Versus Pfannenstiel Incision. J Clin Med 2025; 14:2697. [PMID: 40283527 PMCID: PMC12028115 DOI: 10.3390/jcm14082697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2025] [Revised: 04/05/2025] [Accepted: 04/12/2025] [Indexed: 04/29/2025] Open
Abstract
Background: Recent studies indicate that minimally invasive surgery is widely accepted as the optimal procedure for colorectal cancer. However, the ideal location of the specimen extraction site remains unclear. This study aimed to compare the conventional periumbilical midline incision with the Pfannenstiel incision for specimen extraction during minimally invasive surgery for rectal cancer. Methods: This retrospective cohort study included 76 patients who underwent minimally invasive surgery (double-stapling technique anastomosis) for rectal cancer between January 2022 and June 2023. The postoperative short- and mid-term outcomes were compared between the periumbilical midline incision and Pfannenstiel incision groups. Results: The patients' backgrounds were comparable between the two groups. There were no significant differences in the surgical outcomes or short-term postoperative complications. The Pfannenstiel incision demonstrated advantages, including reduced postoperative pain at rest and during movement, and a lower incidence of incisional hernia (p = 0.038). Conclusions: The Pfannenstiel incision is a safe and effective option associated with reduced postoperative pain and a lower risk of incisional hernia. Therefore, it can serve as a useful alternative for specimen extraction during minimally invasive rectal cancer surgery.
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Affiliation(s)
- Yasuhiro Takeda
- Department of Surgery, The Jikei University School of Medicine, 3-19-18, Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan; (K.G.); (T.K.); (T.A.); (T.N.); (Y.T.); (M.O.); (M.K.); (K.E.)
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3
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Mehdorn M, Schnarkowski B, Stelzner S, Scheuermann U, Kassahun WT, Denecke T, Niebisch S, Meyer HJ. The sagitta in 3D reconstruction of linea alba on routine CT scans is predictive of postoperative burst abdomen. Hernia 2025; 29:117. [PMID: 40069372 PMCID: PMC11897086 DOI: 10.1007/s10029-025-03303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Accepted: 02/22/2025] [Indexed: 03/15/2025]
Abstract
PURPOSE Burst abdomen (BA) is a relevant complication after abdominal surgery that causes additional surgical procedures, prolonged hospital stays and long-term morbidity. Several underlying risk factors exist and have been characterized previously. Those risk factors consist of surgical and medical factors. Recently, CT-derived body composition is of rising interest and 3D reconstruction of the linea alba has been studied. The clinical significance of those parameters is not clear. We therefore performed an analysis of linea alba 3D reconstruction measurements and their prognostic significance on the development of BA. METHODS An institutional data base of patients with post operative wound infections was assembled. The subgroup of patients with BA was compared to controls. If the patients had complete preoperative abdominal CT scans, their images were further analyzed and 3D reconstruction of the linea alba was performed. Subsequently, lineal alba was measured at predetermined positions. Those values were evaluated as risk factors for postoperative BA. RESULTS A total of 72 patients with BA and 32 controls were eligible for the analysis. We found body mass index-related significant differences as well as sex related differences in linea alba width. Furthermore, BA patients had a significantly wider linea alba and longer sagitta compared to controls. In the multivariate analysis of linea alba measurements and clinical parameters, the length of the sagitta was significantly associated with the risk of BA (OR 1.266; 95% CI 1.011-1.585; p = 0.04). CONCLUSION In this study of 3D reconstruction of the linea alba from routine CT scans, we could show that a longer sagitta was associated with an increased risk of postoperative BA.
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Affiliation(s)
- Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Benedikt Schnarkowski
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Sigmar Stelzner
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Uwe Scheuermann
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Woubet Tefera Kassahun
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Timm Denecke
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Stefan Niebisch
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Hans-Jonas Meyer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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4
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Grüter AAJ, Jongsma WA, Leone N, Barai H, Toorenvliet BR, Tanis PJ, Tuynman JB. Nationwide variations in the execution of minimally invasive right hemicolectomy and short-term outcomes: first phase of the RIGHT study. Br J Surg 2024; 111:znae291. [PMID: 39556596 PMCID: PMC11572717 DOI: 10.1093/bjs/znae291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 09/27/2024] [Accepted: 10/30/2024] [Indexed: 11/20/2024]
Affiliation(s)
- Alexander A J Grüter
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Willemijn A Jongsma
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Nicola Leone
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Hasti Barai
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Berger Y, Khajoueinejad N, Imtiaz S, Sarfaty E, Troob S, Park SY, Cha DE, Li TM, Buseck A, Kim E, Li DM, Kim SA, Fong CF, Govindarajulu US, Sarpel U. Robotic colorectal resections are associated with less postoperative pain, decreased opioid use, and earlier return to work as compared to the laparoscopic approach. J Robot Surg 2024; 18:336. [PMID: 39249110 DOI: 10.1007/s11701-024-02054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/18/2024] [Indexed: 09/10/2024]
Abstract
While robotic and laparoscopic surgeries are both minimally invasive in nature, they are intrinsically different approaches and it is critical to understand outcome differences between the two. Studies evaluating pain outcomes and opioid requirement differences between the robotic and laparoscopic colorectal resections are conflicting and often underpowered. In this retrospective, cohort study, we compare postoperative opioid requirements, reported as morphine milligram equivalents (MME), postoperative average and highest pain scores across postoperative days (POD) 0-5, and return to work in patients who underwent robotic versus laparoscopic colorectal resections. The sample size was selected based on power calculations. Daily pain scores and MME were used as outcomes in linear mixed effect models with unstructured covariance between time points. Propensity score weighting was used to adjust for imbalances. Patients in the robotic group required significantly less opioids as measured by MME on all postoperative days (p = 0.004), as well as lower average and highest daily pain scores for POD 0-5 (p = 0.02, and p = 0.006, respectively). In a linear mixed-effects model, robotic resections were associated with a decrease in average pain scores by 0.36 over time (p = 0.03) and 35 fewer MME requirements than the laparoscopic group (p = 0.0004). Patients in the robotic arm had earlier return to work (2.1 vs 3.8 days, p = 0.036). The robotic approach to colorectal resections is associated with significantly less postoperative pain, decreased opioid requirements, and earlier return to work when compared to laparoscopy, suggesting that the robotic platform provides important clinical advantages over the laparoscopic approach.
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Affiliation(s)
- Yael Berger
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Surgery, Rabin Medical Center, Petah Tikva, Israel
| | | | - Sayed Imtiaz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elad Sarfaty
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Surgery, Rabin Medical Center, Petah Tikva, Israel
| | - Samantha Troob
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - So Youn Park
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Da Eun Cha
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas M Li
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alison Buseck
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Esther Kim
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deborah M Li
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sanghyun A Kim
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carmen F Fong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usha S Govindarajulu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Umut Sarpel
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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6
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Abelson JS. Invited Commentary: There Is No Doubt: Avoid Midline Extraction When Feasible in Minimally Invasive Colorectal Surgery to Minimize Risk of Incisional Hernia. J Am Coll Surg 2024; 239:112-113. [PMID: 38415766 DOI: 10.1097/xcs.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
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7
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Wu XW, Yang DQ, Wang MW, Jiao Y. Occurrence and prevention of incisional hernia following laparoscopic colorectal surgery. World J Gastrointest Surg 2024; 16:1973-1980. [PMID: 39087097 PMCID: PMC11287670 DOI: 10.4240/wjgs.v16.i7.1973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/23/2024] [Accepted: 05/31/2024] [Indexed: 07/22/2024] Open
Abstract
Among minimally invasive surgical procedures, colorectal surgery is associated with a notably higher incidence of incisional hernia (IH), ranging from 1.7% to 24.3%. This complication poses a significant burden on the healthcare system annually, necessitating urgent attention from surgeons. In a study published in the World Journal of Gastrointestinal Surgery, Fan et al compared the incidence of IH among 1614 patients who underwent laparoscopic colorectal surgery with different extraction site locations and evaluated the risk factors associated with its occurrence. This editorial analyzes the current risk factors for IH after laparoscopic colorectal surgery, emphasizing the impact of obesity, surgical site infection, and the choice of incision location on its development. Furthermore, we summarize the currently available preventive measures for IH. Given the low surgical repair rate and high recurrence rate associated with IH, prevention deserves greater research and attention compared to treatment.
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Affiliation(s)
- Xi-Wen Wu
- The First Operating Room, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Ding-Quan Yang
- Department of Gastrointestinal and Colorectal Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Ming-Wei Wang
- Ministry of Health Key Laboratory of Radiobiology, School of Public Health of Jilin University, Changchun 130000, Jilin Province, China
| | - Yan Jiao
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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8
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Fefferman ML, Zheng C, Varsanik AM, Vigneswaran Y. Hidden Port Site Incisions for Robotic Foregut and Hepatopancreatobiliary Operations: A Cosmetically Superior Approach. J Am Coll Surg 2024; 239:e1-e6. [PMID: 38634560 DOI: 10.1097/xcs.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Marie L Fefferman
- From the Department of Surgery, The University of Chicago, Chicago, IL
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9
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Amro C, Smith L, Shulkin J, McGraw JR, Hill N, Broach RB, Torkington J, Fischer JP. The enigma of incisional hernia prediction unraveled: external validation of a prognostic model in colorectal cancer patients. Hernia 2024; 28:547-553. [PMID: 38227093 DOI: 10.1007/s10029-023-02947-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/12/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE Accurate prediction of hernia occurrence is vital for surgical decision-making and patient management, particularly in colorectal surgery patients. While a hernia prediction model has been developed, its performance in external populations remain to be investigated. This study aims to validate the existing model on an external dataset of patients who underwent colorectal surgery. METHODS The "Penn Hernia Calculator" model was externally validated using the Hughes Abdominal Repair Trial (HART) data, a randomized trial comparing colorectal cancer surgery closure techniques. The data encompassed demographics, comorbidities, and surgical specifics. Patients without complete follow-up were omitted. Model performance was assessed using key metrics, including area under the curve (AUC-ROC and AUC-PR) and Brier score. Reporting followed the TRIPOD consensus. RESULTS An external international dataset consisting of 802 colorectal surgery patients were identified, of which 674 patients with up to 2 years follow-up were included. Average patient age was 68 years, with 63.8% male. The average BMI was 28.1. Prevalence of diabetes, hypertension, and smoking were 15.7%, 16.3%, and 36.5%, respectively. Additionally, 7.9% of patients had a previous hernia. The most common operation types were low anterior resection (35.3%) and right hemicolectomy (34.4%). Hernia were observed in 24% of cases by 2-year follow-up. The external validation model revealed an AUC-ROC of 0.66, AUC-PR of 0.72, and a Brier score of 0.2. CONCLUSION The hernia prediction model demonstrated moderate performance in the external validation. Its potential generalizability, specifically in those undergoing colorectal surgery, may suggest utility in identifying and managing high-risk hernia candidates.
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Affiliation(s)
- C Amro
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14t Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - L Smith
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - J Shulkin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14t Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - J R McGraw
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14t Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - N Hill
- School of Medicine, Cardiff University, Cardiff, UK
| | - R B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14t Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - J Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14t Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Smith L, Wilkes E, Rolfe C, Westlake P, Cornish J, Brooks P, Torkington J. Incidence, Healthcare Resource Use and Costs Associated With Incisional Hernia Repair. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2024; 3:12452. [PMID: 38481877 PMCID: PMC10936754 DOI: 10.3389/jaws.2024.12452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/06/2024] [Indexed: 07/22/2024]
Abstract
Background: Incisional hernia (IH) is a common complication of abdominal surgery affecting between 12.8% and 30% of patients. In spite of this, rates of IH repair remain low, at around 5% in the literature. We aimed to assess the rate of IH repair in the UK across surgical specialties and the cost burden associated with IH repair. Methods: This is a retrospective observational study of patients undergoing abdominal surgery in England between 2012 and 2022 using the Hospital Episode Statistics (HES) database. Index abdominal surgery was identified between March 2014 and March 2017. Diagnostic and surgical procedure codes were used to identify pre-operative risk factors, index surgeries, IH repair and healthcare contact. Healthcare resource use (HCRU) costs were derived for index surgery and all post-index, non-elective inpatient admissions and outpatient visits using Healthcare Resource Group (HRG) codes within HES. Results: Of 297,134 patients undergoing abdominal surgery, 5.1% (n = 15,138) subsequently underwent incisional hernia repair. By specialty, rates were higher in Colorectal (10.0%), followed by Hepatobiliary (8.2%), Transplant (6.8%), Urological (4.0%), Bariatric (3.5%), Vascular (3.2%) and Gynaecological (2.6%) surgery. Patients undergoing IH repair had more healthcare contacts, longer length of inpatient stays and more A+E visits vs. those with no IH repair post index surgery (83% ≥ 1 A+E visit vs. 69%), as well as higher rates of referral to mental health services (19.8% vs. 11.5%). IH repair was associated with an average HCRU cost of £23,148 compared to £12,321 in patients with no IH repair. Conclusion: Patients undergoing IH repair have a greater morbidity than those not undergoing repair, shown by higher HCRU and more healthcare contacts. Despite this, rates of surgery for IH are low, suggesting that most patients with hernias are not undergoing repair. Emphasis must be placed squarely on primary prevention, rather than cure.
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Affiliation(s)
- Laurie Smith
- Department of Colorectal Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Emily Wilkes
- Real-World Evidence, OPEN Health, Marlow, United Kingdom
| | - Chris Rolfe
- Real-World Evidence, OPEN Health, Marlow, United Kingdom
| | - Petra Westlake
- Real-World Evidence, OPEN Health, Marlow, United Kingdom
| | - Julie Cornish
- Department of Colorectal Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Paul Brooks
- Market Access, Becton Dickinson Surgery UK, Wokingham, United Kingdom
| | - Jared Torkington
- Department of Colorectal Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
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11
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Grüter AAJ, Toorenvliet BR, Belgers EHJ, Belt EJT, van Duijvendijk P, Hoff C, Hompes R, Smits AB, van de Ven AWH, van Westreenen HL, Bonjer HJ, Tanis PJ, Tuynman JB. Nationwide standardization of minimally invasive right hemicolectomy for colon cancer and development and validation of a video-based competency assessment tool (the Right study). Br J Surg 2024; 111:znad404. [PMID: 38103184 PMCID: PMC10763527 DOI: 10.1093/bjs/znad404] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Substantial variation exists when performing a minimally invasive right hemicolectomy (MIRH) due to disparities in training, expertise and differences in implementation of innovations. This study aimed to achieve national consensus on an optimal and standardized MIRH technique for colon cancer and to develop and validate a video-based competency assessment tool (CAT) for MIRH. METHOD Statements covering all elements of MIRH were formulated. Subsequently, the Delphi technique was used to reach consensus on a standardized MIRH among 76 colorectal surgeons from 43 different centres. A CAT was developed based on the Delphi results. Nine surgeons assessed the same 12 unedited full-length videos using the CAT, allowing evaluation of the intraclass correlation coefficient (ICC). RESULTS After three Delphi rounds, consensus (≥80% agreement) was achieved on 23 of the 24 statements. Consensus statements included the use of low intra-abdominal pressure, detailed anatomical outline how to perform complete mesocolic excision with central vascular ligation, the creation of an intracorporeal anastomosis, and specimen extraction through a Pfannenstiel incision using a wound protector. The CAT included seven consecutive steps to measure competency of the MIRH and showed high consistency among surgeons with an overall ICC of 0.923. CONCLUSION Nationwide consensus on a standardized and optimized technique of MIRH was reached. The CAT developed showed excellent interrater reliability. These achievements are crucial steps to an ongoing nationwide quality improvement project (the Right study).
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Affiliation(s)
- Alexander A J Grüter
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Eric H J Belgers
- Department of Surgery, Zuyderland Medisch Centrum, Heerlen, The Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | | | - Christiaan Hoff
- Department of Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Anke B Smits
- Department of Surgery, St.Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | | | - Hendrik J Bonjer
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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12
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Vaghiri S, Prassas D, Krieg S, Knoefel WT, Krieg A. Intracorporeal Versus Extracorporeal Colo-colic Anastomosis in Minimally-invasive Left Colectomy: a Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:3024-3037. [PMID: 37698813 PMCID: PMC10837220 DOI: 10.1007/s11605-023-05827-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/26/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE The primary aim was to investigate the operative outcomes of intracorporeal (IA) and extracorporeal (EA) anastomosis in left-sided minimally-invasive colectomy. METHODS A comprehensive literature search was conducted for studies comparing operative outcomes and follow-up data of IA versus EA in minimally-invasive left colectomy. Studies that investigated recto-sigmoid resections using transanal circular staplers were excluded. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and mean differences with 95 per cent confidence intervals were calculated. RESULTS Eight studies with a total of 750 patients were included (IA n = 335 versus EA n = 415). IA was associated with significantly lower overall morbidity (OR 0.40, 95% CI 0.26-0.61, p < 0.0001) and less frequent surgical site infection (SSI) (OR 0.27, 95% CI 0.12-0.61, p = 0.002) as primary outcomes compared to EA. Of the secondary outcomes, length of incision (SMD -2.51, 95% CI -4.21 to -0.81, p = 0.004), time to first oral diet intake (SMD -0.49, 95% CI -0.76 to -0.22, p = 0. 0004) and time to first bowel movement (SMD -0.40, 95% CI -0.71 to -0.09, p = 0.01) were significantly in favor of IA, while operative time was significantly shorter in the EA group (SMD 0.36, 95% CI 0.14-0.59, p = 0.001). CONCLUSIONS IA proves to be a safe and feasible option as it demonstrates benefits in terms of lower overall morbidity, fewer rates of SSI, smaller incision length, and faster postoperative gastrointestinal recovery despite a longer operative time compared to EA.
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Affiliation(s)
- Sascha Vaghiri
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany
| | - Sarah Krieg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany.
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13
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van Steensel S, Deerenberg EB, Poelman MM. Abdominal wall closure. Br J Surg 2023; 110:1597-1600. [PMID: 37713648 DOI: 10.1093/bjs/znad294] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 09/17/2023]
Affiliation(s)
| | - Eva B Deerenberg
- Department of General Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Marijn M Poelman
- Department of General Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
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14
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Xiang S, Huang S, Ye H, Lu W, Zeng X. Feasibility and safety of specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy: a single-center retrospective comparative study. Front Oncol 2023; 13:1273499. [PMID: 38023201 PMCID: PMC10665085 DOI: 10.3389/fonc.2023.1273499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To investigate the feasibility and safety of specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy. Methods A retrospective analysis of 95 patients with rectal cancer who underwent laparoscopic low anterior rectal resection and skin bridge loop ileostomy between August 2018 and August 2022, including 44 patients with specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy (experimental group) and 51 patients with specimen extraction via an abdominal incision (control group). Following the application of propensity score matching (PSM), 34 pairs of data were successfully matched. Subsequently, a comparative analysis was conducted on the clinical data of the two groups. Results The experimental group exhibited significantly better outcomes than the control group in various aspects. Specifically, the experimental group had lower values for average operative time (P < 0.001), estimated blood loss (P < 0.001), median length of visible incision after surgery (P < 0.001), median VAS pain score on the first day after surgery (P = 0.015), and average postoperative hospitalization (P = 0.001). There was no statistical significance observed in the incidence of stoma-related complications in both groups (P > 0.05). Within each group, the stoma-QOL scores before stoma closure surgery were significantly higher than those at one month and two months after the surgery, with statistical significance (P < 0.05). Conclusion Specimen extraction via a U-Plus skin bridge loop ileostomy is a safe and feasible method that shortens operation time and postoperative visual incision length, decreases estimated blood loss, and reduces patient postoperative pain compared with specimen extraction via an abdominal incision.
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Affiliation(s)
- Shang Xiang
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Shujuan Huang
- Department of Respiratory and Critical Care Medicine, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Hui Ye
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Wei Lu
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Xiangsheng Zeng
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
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15
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Grüter AAJ, Coblijn UK, Toorenvliet BR, Tanis PJ, Tuynman JB. National implementation of an optimal standardised technique for right-sided colon cancer: protocol of an interventional sequential cohort study (Right study). Tech Coloproctol 2023; 27:1083-1090. [PMID: 37097330 PMCID: PMC10562307 DOI: 10.1007/s10151-023-02801-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE Minimally invasive right hemicolectomy (MIRH) is the cornerstone of treatment for patients with right-sided colon cancer. This operation has evolved during recent decades, with many innovations and improvements but this has also resulted in high variability of uptake with subsequent substantial variableness. The aim of this ongoing study is to identify current surgical variations, determine the most optimal and standardised MIRH and nationally train and implement that technique to improve short-term clinical and long-term oncological outcomes. METHODS The Right study is a national multicentre prospective interventional sequential cohort study. Firstly, current local practice was evaluated. Subsequently, a standardised surgical technique for right-sided colon cancer was determined using the Delphi consensus method, and this procedure was trained during hands-on courses. The standardised MIRH will be implemented with proctoring (implementation cohort), after which the performance will be monitored (consolidation cohort). Patients who will receive a minimally invasive (extended) right hemicolectomy for cT1-3N0-2M0 colon cancer will be included. The primary outcome is patient safety reflected in the 90-day overall complication rate according to the Clavien-Dindo classification. Secondary outcomes will include intraoperative complications, 90-day mortality rate, number of resected tumour-positive lymph nodes, completeness of mesocolic excision, surgical quality score, locoregional and distant recurrence and 5-year overall survival. A total number of 1095 patients (365 per cohort) will be included. DISCUSSION The Right study is designed to safely implement the best surgical practice concerning patients with right-sided colon cancer aiming to standardise and improve the surgical quality of MIRH at a national level. TRIAL REGISTRATION ClinicalTrials.gov: NCT04889456, May 2021.
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Affiliation(s)
- Alexander A J Grüter
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - Usha K Coblijn
- Department of Surgery, Antoni van Leeuwenhoek, Plesmanlaan 121, Amsterdam, The Netherlands
| | | | - Pieter J Tanis
- Department of Surgery, UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Surgery, Erasmus MC, Dr. Molewaterplein 40, Rotterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
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Kobayashi T, Miki H, Yamamoto N, Hori S, Hatta M, Hashimoto Y, Mukaide H, Yamasaki M, Inoue K, Sekimoto M. Retrospective study of an incisional hernia after laparoscopic colectomy for colorectal cancer. BMC Surg 2023; 23:314. [PMID: 37845691 PMCID: PMC10580507 DOI: 10.1186/s12893-023-02229-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023] Open
Abstract
PURPOSE This study aimed to examine the incidence of incisional hernia (IH) in elective laparoscopic colorectal surgery (LC) using regulated computed tomography (CT) images at intervals every 6 months. METHODS We retrospectively examined the diagnosis of IH in patients who underwent LC for colorectal cancer at Kansai Medical University Hospital from January 2014 to August 2018. The diagnosis of IH was defined as loss of continuity of the fascia in the axial CT images. RESULTS 470 patients were included in the analysis. IH was diagnosed in 47 cases at 1 year after LC. The IH size was 7.8 cm2 [1.3-55.6]. In total, 38 patients with IH underwent CT examination 6 months after LC, and 37 were already diagnosed with IH. The IH size was 4.1 cm2 [0-58.9]. The IH size increased in 17 cases between 6 months and 1 year postoperatively, and in 1 case, a new IH occurred. 47%(18/38) of them continued to grow until 1 year after LC. A multivariate analysis was performed on the risk of IH occurrence. SSI was most significantly associated with IH occurrence (OR:5.28 [2.14-13.05], p = 0.0003). CONCLUSION IH occurred in 10% and 7.9% at 1 year and 6 months after LC. By examining CT images taken for the postoperative surveillance of colorectal cancer, we were able to investigate the occurrence of IH in detail.
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Affiliation(s)
- Toshinori Kobayashi
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Hisanori Miki
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Nobuyuki Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Soushi Hori
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Masahiko Hatta
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Yuki Hashimoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Hiromi Mukaide
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Makoto Yamasaki
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan.
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17
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Olumba FC, Vachharajani N, Yu J, Scherer M, Matson S, Hill AL, Kiani A, Lin Y, Doyle MMB, Chapman WC, Wellen JR, Khan AS. Robotic donor nephrectomy: optimizing outcomes beyond the limitations of laparoscopy. Surg Endosc 2023; 37:7511-7519. [PMID: 37415014 DOI: 10.1007/s00464-023-10246-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Robotic donor nephrectomy (RDN) has emerged as a safe alternate to laparoscopic donor nephrectomy (LDN), offering improved visualization, instrument dexterity and ergonomics. There is still concern about how to safely transition from LDN to RDN. METHODS We performed a retrospective review of 150 consecutive living donor operations (75 LDN and 75 RDN) at our center, comparing the first 75 RDN's with the last 75 LDN's performed prior to the initiation of the robotic transplant program. Operative times and complications were used as surrogates of efficiency and safety, respectively, to estimate the learning curve with RDN. RESULTS RDN was associated with a longer total operative time (RDN 182 vs LDN 144 min; P < 0.0001) but a significantly shorter post-operative length of stay (RDN 1.8 vs LDN 2.1 days; P = 0.0213). Donor complications and recipient outcomes were the same between both groups. Learning curve of RDN was estimated to be about 30 cases. CONCLUSIONS RDN is a safe alternate to LDN with acceptable donor morbidity and no negative impact on recipient outcomes even during the early part of the RDN learning curve. Surgeon preferences for the robotic approach compared to traditional laparoscopy will require further scrutiny to improve ergonomics and operative efficiency.
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Affiliation(s)
- Franklin C Olumba
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Neeta Vachharajani
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Jennifer Yu
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Meranda Scherer
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Sarah Matson
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Angela L Hill
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Amen Kiani
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Yiing Lin
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Majella M B Doyle
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - William C Chapman
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Jason R Wellen
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA
| | - Adeel S Khan
- Department of Surgery, Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO, 63110, USA.
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18
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Takagi K, Umeda Y, Yoshida R, Fuji T, Yasui K, Kimura J, Hata N, Yagi T, Fujiwara T. Role of the Pfannenstiel Incision in Robotic Hepato-Pancreato-Biliary Surgery. J Clin Med 2023; 12:jcm12051971. [PMID: 36902758 PMCID: PMC10004448 DOI: 10.3390/jcm12051971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Studies remain limited on the role of the Pfannenstiel incision in minimally invasive hepato-pancreato-biliary (HPB) surgery, especially robotic surgery. The role of various extraction sites in robotic HPB surgery should be understood. Herein, we describe the surgical techniques, outcomes, advantages, and disadvantages of the Pfannenstiel incision in robotic pancreatic surgery. Seventy patients underwent robotic pancreatectomy at our institution between September 2020 and October 2022. The Pfannenstiel incision was used for specimen retrieval in 55 patients. Advantages of the Pfannenstiel incision include less pain, cosmetic benefits, and a lower incidence of complications. Moreover, the specimen could be removed using the robotic system docked. However, all complex reconstructions should be performed intra-abdominally during robotic pancreatoduodenectomies. The incidence of mortality and postoperative pancreatic fistula (grade B) was 0% and 9.1%, respectively. During the median follow-up (11.2 months) after surgery, complications at the Pfannenstiel incision site included surgical site infection (n = 1, 1.8%) and incisional hernia (n = 1, 1.8%). The Pfannenstiel incision can be a useful option for specimen retrieval in minimally invasive HPB surgery, according to the surgeon's preferences and the patient's condition.
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