Faculty Bibliography

PURPOSE/OBJECTIVE:The aim of this paper is to compare outcomes of patients who underwent combined gynecologic procedures with ventral hernia repair (VHR) with patients that underwent only VHR. METHODS:Patients who underwent VHR with a combined gynecological procedure from 2012 to 2023 were retrospectively identified in the Abdominal Core Health Quality Collaborative and categorized into two groups with surgical wound contamination in mind. Group one included patients with concomitant salpingo-oophorectomy (SO), bilateral tubal ligation (BTO), and/or ovarian cystectomy (OC) without hysterectomy. Group two consisted of patients who underwent hysterectomy with or without SO/BTO/OC/ER. C-Sections were excluded. Mesh location was 90% in the sublay space for both groups. Patients who underwent VHR without any concomitant procedure were the control group. Propensity score matching (PSM; ratio 3:1 for control vs. group one and 1:1 for control vs. group two) was performed based on relevant demographic and perioperative covariates (age, hernia width, operative approach, ASA class, BMI, mesh used, current smoker, wound status, year of operation, and recurrent). Postoperative outcomes at 30 days were compared between group one and control and between group two and control based on post-PSM cohorts. RESULTS:Out of 13,982 patients undergoing VHR, 279 (2%) also underwent a concurrent gynecological procedure. Following PSM, 88 patients in Group 1 were matched with 264 patients that underwent VHR alone. Similarly, 186 patients in Group 2 were compared with 186 patients in the control group. Operative time was significantly higher in both groups as compared to control (p < 0.001). A longer LOS and more EBL were observed group 2 but not group 1. No statistically significant differences were observed in either group regarding surgical site infection (SSI), surgical site occurrence (SSO), Surgical site occurrences requiring procedural interventions (SSOPI), recurrence of hernia, reoperations, or readmissions. CONCLUSION/CONCLUSIONS:This study compares the outcomes of patients that underwent VHR with simultaneous gynecological procedure to patients with VHR alone. Combining hernia repair and gynecologic surgery did not appear to have an adverse impact on clinical outcomes. Our study suggests that further collaboration between gynecology and general surgery can be considered for management of concurrent abdominopelvic pathologies.

BACKGROUND:Minimally invasive surgery (MIS) for patients undergoing inguinal hernia repair (IHR) after prostatectomy has been considered a challenging procedure due to the presence of scar tissue and adhesions. We aimed to compare the outcomes of open and MIS IHR outcomes in post-prostatectomy patients through a systematic review and proportional meta-analysis. MATERIAL & METHODS/METHODS:PubMed/MEDLINE, Embase, Cochrane, and Web of Science were searched for studies on open and MIS IHR after prostatectomy. Outcomes such as recurrence, complications, seroma, hematoma, SSI, and conversion rates were analyzed, with subgroup analyses conducted for open, TEP, and TAPP procedures. RESULTS:Among 402 screened studies, 18 met the inclusion criteria, covering 8,668 open IHR (64.6%) and 4,761 MIS IHR (35.4%) patients. The rate per 100 events for intraoperative complications was 0.19 (95% CI [0.00; 0.76]; I2 = 71%;), 5.22 per 100 for seroma (95% CI [2.86; 9.34]; I2 = 92%), 0.83 per 100 for SSI (95% CI [0.39; 1.75]; I2 = 48%), 3.16 per 100 for hematoma (95% CI [1.16; 8.31]; I2 = 84%), 3.02 per 100 patients for chronic pain (95% CI [2.53; 3.62]; I2 = 13%), and 0.02 per 100 for recurrence (95% CI [0; 0.16]; I2 = 10%). The conversion rate for MIS was 1.66 per 100 (95% CI [0.89; 3.06]; I2 = 0%). Subgroup analysis revealed no significant difference between TEP and TAPP in intraoperative complications (p = 0.70), but a lower seroma rate in TAPP compared to TEP (5.29 vs. 20 per 100; P = 0.01). MIS had significant reduction in SSI (0.08 vs. 0.34 per 100; P < 0.01), hematoma (1.29 vs. 17.86; p < 0.01), and recurrence (0.08 vs. 0.37; p = 0.04) compared to open, with no difference in seroma rates. Funnel plots revealed no evidence of publication bias. CONCLUSIONS:In experienced hands, MIS IHR is a safe and effective option for post-prostatectomy patients, with lower complication rates compared to open IHR, although high-quality comparative studies are needed to establish definitive conclusions. PROSPERO REGISTRATION/UNASSIGNED:July 7, 2024 (ID CRD42024562863).

BACKGROUND:Postoperative pain remains a common concern following ventral hernia repair (VHR), especially for open procedures. We aim to assess the effectiveness of the Transversus Abdominis Plane (TAP) block for the management of postoperative pain following VHR. METHODS:) for TAP block. RESULTS:. CONCLUSIONS:The TAP block is associated with shorter LOS compared to placebo and epidural analgesia and is related to less early postoperative pain compared to the conventional pain measures. The TAP block should be considered as a pain management modality for VHR, however cost-effective analysis is required to address the feasibility of the routine utilization of this approach and to balance the financial benefits of its application.

BACKGROUND:Posterior component separation with transversus abdominis release (TAR) is a valuable adjunct to address incisional hernia defects. Currently, bilateral docking is a standard technique for robotic TAR. The aim of this study is to describe our technique for extended totally extraperitoneal (eTEP) repair with bilateral TAR through a bottom single-dock robotic approach for hernias at the level of the umbilicus or higher. MATERIALS AND METHODS/METHODS:We retrospectively reviewed a case series of patients who underwent robotic eTEP repair with bilateral TAR using a single bottom docking between November 2021 and November 2023. A comprehensive description of our patient selection, surgical technique, and short-term clinical outcomes is reported. RESULTS:Ten patients with incisional hernias were included. Their median age was 55 years (IQR: 49.5 to 61.25), 70% were male, the median BMI was 27.25 kg/m (IQR: 22.95 to 33.53), and ASA class was ≥2 in 80%. Median hernia width was 10 cm (IQR: 6.75 to 12.25) and length 11 cm (IQR: 9.25 to 16.25). The median operative time was 178.5 minutes (IQR: 153.75 to 222), and the length of stay was 1 day (IQR: 0.75 to 1.75). At a median follow-up of 5 months (IQR: 2.6 to 9.7), 20% of patients developed a surgical site occurrence requiring procedural intervention. CONCLUSION/CONCLUSIONS:Bilateral TAR using a single bottom dock is a feasible and safe adjunct to robotic eTEP ventral hernia repair in appropriately selected patients.

INTRODUCTION/UNASSIGNED: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/UNASSIGNED: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/UNASSIGNED: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/UNASSIGNED: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.

INTRODUCTION/BACKGROUND:Closure of large hernia defects with minimally invasive surgery has long-been a challenge. Barbed sutures have helped us bridge this technical gap, but their off-label use is not well studied. MATERIALS AND METHODS/METHODS:We describe a suturing technique for minimally invasive ventral hernia repair (MIS-VHR) termed "progressive defect tensioning" and explore its theoretical advantages. Progressive defect tensioning utilizes barbed sutures to progressively and evenly re-approximate the fascia along the entire defect length. Tension is then sequentially applied to each throw, distributing the load across multiple anchor points along the closure. This redistribution of tension is explained using a physics model to depict its theoretical benefit. We also explore how biomechanical properties, such as tissue creep and hysteresis, impact closure of complex defects. RESULTS:Our initial, proof-of-concept cohort of 12 patients with hernias larger than 10 cm undergoing MIS-VHR had acceptable perioperative outcomes compared to the literature. CONCLUSIONS:Ultimately, progressive defect tensioning leverages the properties of barbed sutures and the biomechanics of fascia to achieve optimal tension distribution during MIS-VHR.

AIM/OBJECTIVE:Minimally invasive inguinal hernia repair has become increasingly accepted, demonstrating superior outcomes over open procedures in postoperative complications. However, certain postoperative complications, such as seroma, remain a dilemma, with many attributing it to the management of the hernia sac. We aimed to perform a systematic review and meta-analysis comparing the reduction versus abandonment of the hernia sac during laparoscopic inguinal hernia repair. MATERIAL AND METHODS/METHODS:Cochrane, Scopus, SciELO, and PubMed were searched for studies comparing reduction and abandonment of the hernia sac. Our primary outcome was seroma. Secondary outcomes were overall complications, postoperative pain, surgical site infection, recurrence, hospital length of stay (LOS), and operative time. We performed a subgroup analysis of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. Statistical analysis was performed with R Studio. RESULTS:2388 studies were screened, and seven studies were included, comprising 3153 patients, of which 916 (29%) were in the abandonment group. We found higher seroma rates for the abandonment group (RR 1.52; 95% CI 1.22 to 1.89; P < 0.001). No differences were found in overall complications (RR 0.88; 95% CI 0.55 to 1.42; P = 0.61), postoperative pain (RR 1.15; 95% CI 0.46 to 2.87; P = 0.76), recurrence (RR 2.67; 95% CI 0.51 to 14.05; P = 0.25), operative time (MD - 4.45 min; 95% CI - 12.77 to 3.86; P = 0.29), and LOS (MD -0.06 days; 95% CI - 0.14 to 0.02; P = 0.14) between both groups. Subgroup analysis of seroma showed no differences between the groups when analyzing TAPP (19.3% vs. 13%; RR 1.65; 95% CI 0.91 to 2.99; P = 0.1) and TEP (9% vs. 4.3%; RR 1.69; 95% CI 0.62 to 4.6; P = 0.3) procedures. CONCLUSION/CONCLUSIONS:Our systematic review and meta-analysis support that hernia sac abandonment may be associated with increased early seroma rates following laparoscopic inguinal hernia repair, but limited data are available for technique-specific analyses.