Faculty Bibliography

BACKGROUND:Abdominal wall reconstruction (AWR) carries significant postoperative morbidity, including surgical site infection, wound dehiscence, and readmission. Frailty and sarcopenia have emerged as critical predictors of surgical outcomes; however, their role in AWR is not well defined. We aimed to evaluate the independent and combined predictive value of frailty and sarcopenia proxies on morbidity and mortality after AWR. METHODS:A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted from 2015 to 2020. Frailty was assessed using the Modified Frailty Index (mFI-5), and sarcopenia proxies were defined by ≥ 1 validated proxy markers (BMI < 20, > 10% weight loss/malnutrition, hypoalbuminemia, hematocrit < 30%). Propensity score matching (PSM) was performed to create balanced cohorts, and conditional logistic regression on matched pairs was used to evaluate associations between frailty, sarcopenia proxies, and postoperative outcomes. Primary outcomes were 30-day morbidity and mortality. RESULTS:15,466 adult patients undergoing elective AWR were included. Frailty and sarcopenia proxies were present in 19.4% and 11.3% of patients, respectively. After propensity score matching, frailty was associated with increased odds of overall morbidity (OR 1.16, 95% CI 1.01-1.32; p = 0.035), major complications (OR 1.27, 95% CI 1.07-1.52; p = 0.008), and discharge to a non-home facility (OR 1.40, 95% CI 1.09-1.80; p = 0.008). Sarcopenia proxies demonstrated similar associations. The combined frailty and sarcopenia-proxy phenotype (dual-impairment) conferred the highest odds of morbidity, major complications, and discharge to a non-home facility. Thirty-day mortality and operative time did not differ significantly between groups after matching. CONCLUSION/CONCLUSIONS:Frailty and sarcopenia proxies are prevalent among patients undergoing elective AWR and are independently associated with increased postoperative morbidity, with their coexistence (dual-impairment) conferring the greatest risk. Incorporating these factors into risk calculators may improve patient selection, nutritional optimization, and prehabilitation strategies in complex hernia repair.

BACKGROUND:Parastomal hernia repair is technically complex and associated with substantial morbidity, yet disparities in outcomes among racial groups have not been evaluated. Identifying inequalities in this population may inform strategies to improve access and perioperative care. METHODS:The ACS-NSQIP database from 2013 to 2023 was queried for adults undergoing parastomal hernia repair. Demographics, comorbidities, and operative details were compared among White patients, Black patients, and Hispanic patients. Primary outcomes included 30-day morbidity, infectious complications, and length of stay (LOS). Multivariable logistic and linear regression models were performed using a two step forward selection model adjusting for comorbidities and surgical details. RESULTS:A total of 3,513 patients were included (White 85, Black 8, Hispanic 7%). Black patients had higher unadjusted rates of morbidity (38 vs 30 White, 32% Hispanic; p = 0.023), serious complications (20 vs 13% white vs 13% Hispanic, p = 0.008), infectious complications (20 vs 13 White, 15% Hispanic; p = 0.004), and longer median LOS (6 vs 5 days White, 6 days Hispanic; p = 0.005). On multivariable analysis, Black race remained independently associated with increased odds of overall morbidity (aOR 1.31, 95% CI 1.01-1.70; p = 0.043), serious complications (aOR 1.65; CI 1.15-2.34, p = 0.006), and infectious complications (OR 1.44, 95% CI 1.04-1.98, p = 0.026) compared to white patients. CONCLUSION/CONCLUSIONS:This is the first national study to characterize racial disparities in parastomal hernia repair. Black patients experienced higher morbidity, infectious complications, and length of stay compared to White patients, while Hispanic patients did not differ from White patients. Disparities were emphasized in emergent cases, suggesting that barriers to timely elective repair possible drive imbalances in parastomal hernia repair, warranting interventions for underserved populations, with early referral, equal access, and tailored perioperative support.

PURPOSE/OBJECTIVE:The aim of this study was to compare robotic-assisted versus laparoscopic techniques in elective primary minimally invasive inguinal hernia repair, focusing on intraoperative conversion rates, perioperative outcomes, and preoperative risk factors. Given the increasing adoption of robotic surgery, we sought to evaluate whether the proposed technical advantages translate into measurable clinical benefits in a real-world, multicenter population using a nationally representative database. METHODS:A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2022-2023). Adult patients undergoing elective minimally invasive inguinal hernia repair were identified using CPT code 49650. Patients were stratified into robotic and laparoscopic cohorts. Primary outcomes included conversion to open surgery and operative time; secondary outcomes included 30-day complications, mortality, hospital length of stay, and readmission. Statistical analyses included univariate and multivariate logistic regression. RESULTS:Of 34,257 cases analyzed, 54.9% were robotic and 45.1% laparoscopic. Robotic cases had significantly lower conversion to open rates (0.1% vs. 0.4%, p < 0.001) but longer operative times (82.5 vs. 65 min, p < 0.001). Perioperative complications, mortality, and readmission rates were comparable between groups. Multivariate analysis showed robotic surgery as an independent protective factor against conversion (OR 0.36, 95% CI: 0.22-0.57, p < 0.001). CONCLUSION/CONCLUSIONS:Robotic-assisted inguinal hernia repair is associated with a lower conversion rate to open surgery without increased complications, despite longer operative times and a higher comorbidity burden. These findings support the selective use of robotics, particularly in complex cases, while highlighting the need for further cost-effectiveness and long-term outcomes research.

INTRODUCTION/BACKGROUND:Barbed sutures in ventral hernia repair have been used increasingly. The impact that barbed sutures has on operative time in other procedures is well documented but few reports on ventral hernia repair exist. Furthermore, the use of barbed sutures varies across surgical approaches. The aim of this study was to explore the operative time for ventral hernia repair elucidated by open, laparoscopic, or robotic approach. METHODS:Patients who underwent ventral hernia repair with fascial closure from 2020 to 2022 from the Abdominal Core Health Quality Collaborative were included. Propensity score matching 1:1 with covariates of age, American Society of Anesthesiologists class, recurrent, wound status, incisional procedure, hernia width, mesh used and type, mesh location, body mass index capped at 15 to 60, and concomitant procedures was performed by operative approach. The primary outcome of interest was operative time, and secondary outcomes were length of stay, surgical site infections, surgical site occurrences, surgical site occurrences requiring procedural intervention at 30-day follow-up. RESULTS:A total of 2,230 patients were included in propensity score matchings: open ventral hernia repair (n = 1,434), laparoscopic ventral hernia repair (n = 252), and robotic ventral hernia repair (n = 544). Operative time was more frequently >2 hours in robotic ventral hernia repair using nonbarbed sutures (58% vs 47%; P = .006) and was similar for open (60% vs 57%; P = .2) or laparoscopic (15% vs 21%; P = .2) approach. Across all operative modalities, using barbed sutures was strongly associated with fixation of mesh with sutures, closure of fascia in a running fashion, and more versatility in mesh locations, specifically in laparoscopic ventral hernia repair. Open ventral hernia repair had a shorter length of stay in patients with barbed sutures (2 vs 3; P = .003); however, a reoperation was more common in this same group (3% vs 1%; P = .03), specifically for recurrence (1% vs 0%; P = .04). All the other 30-day outcomes were similar across surgical approaches. CONCLUSION(S)/CONCLUSIONS:The usage of barbed sutures was associated with shorter operative time for robotic procedures and appears to influence the overall technique used in ventral hernia repair. Higher complexity laparoscopic ventral hernia repair performed with barbed sutures had a similar operative time to simpler ventral hernia repair performed with nonbarbed sutures. Open ventral hernia repair with barbed sutures might experience an increase in early recurrences. Further studies are needed.

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:There is no gold standard for recurrent weight gain following Roux-en-Y gastric bypass (RYGB). Combining jejuno-jejunostomy distalization type 1 (JJD1) and sleeve resection of the gastrojejunostomy and gastric pouch (GJ-P) may be a potential approach for these patients. OBJECTIVES/OBJECTIVE:To describe 1-year perioperative and nutritional outcomes of patients who underwent JJD1 with sleeve resection of the GJ-P. SETTING/METHODS:High-volume academic bariatric center of excellence. METHODS:Patients with recurrent weight gain after RYGB who underwent JJD1 with sleeve resection of the GJ-P from 2020 to 2022 were included and studied for 1 year postoperatively. During the procedure, we aimed for a total alimentary limb length (TALL) of 350-500 cm, a new common channel (CC) of 200-350 cm, and a gastrojejunostomy <2 cm in diameter. RESULTS:, respectively. At 1 year, the total weight loss (%TWL) was 22.18%. Only 3 (n = 3) patients developed major complications at 1 year. After distalization, the resolution of all obesity-related co-morbidities improved, including type 2 diabetes (3.2%), sleep apnea (13.1%), hypertension (HTN) (11.4%), and hyperlipidemia (HLD) (1.6%). CONCLUSIONS:The combination of JJD1 and sleeve resection of the GJ-P for RYGB revision was safe and effective, with substantial improvement in weight loss at 1 year.

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/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.