Concomitant midline ventral and inguinal hernia repair: can we create an algorithmic approach?

PURPOSE

International guidelines exist for surgical treatment of either ventral or inguinal hernias repair (VHR; IHR). However, approach for managing both of them remains unestablished and is further complicated by newly developed surgical techniques and modalities (namely, robotic). This highlights the need for a tailored, algorithmic strategy to streamline surgical management.

METHODS

An algorithm was developed by the directors of the NYU Langone Abdominal Core Health program of which four treatment groups were described: Group 1: open VHR and either laparoscopic or robotic IHR; Group 2: robotic transabdominal pre-peritoneal (TAPP) approach for both VHR and IHR; Group 3: robotic retro-muscular VHR and IHR; and Group 4: open repair for both. Demographics, comorbidities, operative characteristics, and surgical outcomes from November 2021 to July 2023 were retrospectively compared.

RESULTS

Ninety-two patients were included with a median age of 64 years, 90% (n = 83) were white, 85% (n = 78) were male, median BMI was 27 kg/m2, and 73% (n = 67) were ASA class II. Distribution of groups was: 48% (n = 44) in 1A, 8% (n = 7) in 1B, 8% (n = 7) in 2A, 3% (n = 3) in 2B, 23% (n = 21) in 3A, 8% (n = 7) in 3B, and 3% (n = 3) in 4. Ventral hernia size, OR time, and postoperative length of stay varied across groups. Postoperative outcomes at 30 days including emergency consults, readmissions, and complications, showed no differences across groups.

CONCLUSION

Access without guidance to new minimally invasive surgical approaches can be a challenge for the general surgeon. We propose an algorithm for decision-making based on our experience of incorporating robotic surgery, when available, for repair of concomitant VHR and IHR with consistent favorable outcomes within a small sample of patients.

Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes

PURPOSE

Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias.

METHODS

A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried.

RESULTS

Sixty-seven male patients [median age: 51.6 years; interquartile range (IQR): 45-65 years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date.

CONCLUSION

We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Understanding the benefits of botulinum toxin A: retrospective analysis of the Abdominal Core Health Quality Collaborative

This was a retrospective analysis of a prospectively maintained database that objectively evaluated the benefit of preoperative chemical component separation with botulinum toxin A in complex hernia repairs.

Continued evaluation.

An international surgical collaboration: humanitarian surgery in Brazil

PURPOSE

Brazil is the fifth most populous country in the world with widespread regional and social inequalities. Regional disparities in healthcare are unacceptably large, with the remote and poor regions of the north and northeast having reduced life expectancy compared to the south region, where life expectancy approaches that of rich countries. We report our experience of a humanitarian surgery mission to the Amazonas state, in the northwest part of Brazil.

METHODS

In August 2014, a team of seven consultant surgeons, and two trainees with the charity 'International Hernia', visited three hospitals in the Amazonas state to provide hernia surgery and training.

RESULTS

Eighty-nine hernias were repaired in 74 patients (female = 22, male = 52) with a median age of 44 years (range 2-83 years). Nine patients underwent more than one type of hernia repair, and there were 9 laparoscopic inguinal and ventral incisional hernia repairs. Local doctors were trained in hernia repair techniques, and an International Hernia Symposium was held at the University of the State of Amazonas, Manaus.

CONCLUSION

The humanitarian mission provided hernia surgery to an underserved population in Brazil and training to local doctors, building local sustainability. Continued cooperation between host and international surgeons for future missions to Brazil will ensure continuing surgical training and technical assistance.