Faculty Bibliography

AIM/OBJECTIVE: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/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: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/CONCLUSIONS: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/UNASSIGNED:CRD42024540991.

PURPOSE/OBJECTIVE:Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair. SOURCE/METHODS:A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma. PRINCIPAL FINDINGS/RESULTS:Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes. CONCLUSION/CONCLUSIONS:This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair. PROSPERO REGISTRATION/UNASSIGNED:ID CRD42024517640.

PURPOSE/OBJECTIVE:Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR. METHODS:We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%. RESULTS: = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay. CONCLUSION/CONCLUSIONS:The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs. STUDY REGISTRATION/BACKGROUND:A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

BACKGROUND:Ventral hernia repair (VHR) is often performed in patients with obesity. While panniculectomy improves cosmetic outcomes, it may increase complications, particularly wound-related adverse events. Despite its widespread use, the impact of concurrent panniculectomy on postoperative complications in VHR remains unclear. This study aimed to assess whether concurrent panniculectomy increases postoperative complications in VHR. METHODS:statistics. RESULTS: = 56%). There was no significant difference in ocurrence of DVT, enterocutaneous fistula, hematoma, seroma, or wound dehiscence, neither on operative time or readmission rates. CONCLUSION/CONCLUSIONS:VHR-PAN is associated with lower recurrence rates. However, it increases the risk of wound morbidity and reoperation and prolongs hospital stay. Surgeons should carefully weigh the risks and benefits of performing VHR-PAN. STUDY REGISTRATION/BACKGROUND:A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024542721).

BACKGROUND:Given the 4-times higher prevalence of femoral hernias among females compared to males, this diagnosis may be missed during inguinal hernia repair (IHR), causing risk of reoperation for pseudo recurrence of femoral hernias (FH). Minimally invasive approaches are suggested as potential reducers of missed FH since they provide a posterior view of all defect areas, despite studies suggesting that women receive less MIS than men. We aim to assess the missed FH during IHR and after reoperation for recurrence following IHR in women. METHODS:PubMED, Cochrane, and EMBASE databases were searched for studies assessing patients undergoing recurrent IHR, analyzing the incidence of reoperation for FH and occult femoral hernias during IHR. Statistical analysis was performed using R software. RESULTS:From 6,226 records, 10 retrospective observational studies were included, totaling 15,863 patients (20% females). We found that 19.56 per 100 women (95% CI 8.34, 39.37) who are reoperated for an inguinal hernia are found as having a FH during the new repair. Compared to men, women were at a significantly higher risk to be reoperated for FH after IHR (RR 8.97; 95% CI 7.35, 10.93; P < 0.001). Our analysis also showed that 20.7% of females received MIS approaches for groin hernia repair, while 79.3% received open procedures. Furthermore, our study found a pooled incidence of occult FH during the initial IHR of 6.85 per 100 patients for both genders (95% CI 2.78, 15.90), which increased to 21.42 per 100 patients when assessing females only (95% CI 15.46, 28.89). CONCLUSIONS:Females have a higher incidence of FH following reoperation for recurrence of inguinal hernia repair. Added to the high rate of occult FH encountered during inguinal procedures, this suggests a missed diagnosis of FH during IHR. The adoption of MIS IHR for women is fundamental to reduce the underdiagnosis of FH.

OBJECTIVE:We aim to perform a systematic review and meta-analysis to analyze the efficacy and safety of low-cost meshes compared to polypropylene meshes for IHR. METHODS:We searched Pubmed, Embase, Cochrane, and Web of Science for randomized controlled trials (RCTs) comparing low-cost and standard meshes for IHR. Low-cost mesh was defined as a material non-designed for medical use. The primary outcomes analyzed were postoperative pain, recurrence, surgical site infection (SSI), seroma, and hematoma rates. Statistical analysis was done using R software. RESULTS: = 0%) rates. CONCLUSION/CONCLUSIONS:This meta-analysis found similar postoperative complication rates for both low-cost and standard polypropylene meshes following IHR. PROSPERO REGISTRATION/UNASSIGNED:ID CRD42024555273.

BACKGROUND:Barbed sutures (BS) have been increasingly used in the last two decades across surgical disciplines but little is known about how widespread their adoption has been in ventral hernia repair (VHR). The aim of this study was to document the use of barbed sutures in VHR in a multicenter database with associated clinical and patient-reported outcomes. METHOD/METHODS:Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent VHR with fascial closure from 2020 to 2022. A univariate analysis compared patients with BS against non-barbed sutures (NBS) across the preoperative, intraoperative, and postoperative timeframes including patient-reported outcomes concerning quality of life and pain scores. RESULTS:A total of 4054 patients that underwent ventral hernia repair with BS were compared with 6473 patients with non-barbed sutures (NBS). Overall, BS were used in 86.2% of minimally invasive ventral hernia repairs and about 92.2% of robotic surgery compared to only 9.6% of open procedures. Notable differences existed in patient selection, including a higher BMI (32 vs 30.5; p < 0.001), more incisional hernias (63.3% vs 51.1%; p < 0.001), wider hernias (4 cm vs 3 cm; p < 0.001), and higher ASA score (p < 0.001) in patients with BS. Outcomes in patients with BS included a shorter length of stay (mean days; 1.4 vs 2.4; p < 0.001), less SSI (1.5% vs 3.6%; p < 0.001), while having similar SSO (7.6% vs 7.3%; p = 0.657), readmission (3.0 vs 3.2; p = 0.691), and reoperation (1.5% vs 1.45%; p = 0.855), at a longer operative time (p < 0.001). Hernia-specific questionnaires for quality of life (HerQLes) and pain in patients with BS had a worse preoperative score that was later matched and favorable compared to NBS (p = 0.048). PRO concerning hernia recurrence suggest around 10% at two years of follow-up (p = 0.532). CONCLUSION/CONCLUSIONS:Use of barbed sutures in VHR is widespread and highly related to MIS. Outcomes from this multicenter database cannot be reported as superior but suggest that barbed sutures do not have a negative impact on outcomes.