Faculty Bibliography

BACKGROUND:Randomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain. METHODS:The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II-IV) ventral hernia repair (2013-2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh. RESULTS:A total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53-70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12-25) and 13 cm (IQR 8-16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups. CONCLUSION/CONCLUSIONS:In the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.

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: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: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.

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.

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.

PURPOSE/OBJECTIVE:Transabdominal preperitoneal (TAPP) ventral hernia repair requires incising the peritoneum from within the abdominal cavity, developing a flap, and placing a reinforcing mesh after fascial closure from the preperitoneal space. We present a novel adaptation to this technique that allows placement of preperitoneal mesh without entering the abdominal cavity. The robotic totally extra- and preperitoneal (R-PeTEP) access for ventral hernia repair is best suited for small to moderate sized ventral hernias with concomitant diastasis recti. METHODS:Our study is a retrospective review of all patients who underwent R-PeTEP from December 2022 to November 2023. A comprehensive description of the surgical technique is included. Patient demographics, hernia characteristics, as well as clinical outcomes are described. RESULTS:A total of 25 patients underwent R-PeTEP for ventral hernia repair with diastasis recti plication. The median age was 55 years (IQR 43.5-63) and 92% (n = 23) were male. The median ASA score was 2 (IQR 1-2) and the median BMI was 30.4 (IQR 29.3-32.8) with 64% (n = 16) percent having a BMI ≥ 30. Median hernia width was 3 cm (IQR 3-4), with a median diastasis recti width of 4 cm (IQR 2.6-4) and length of 15 cm (IQR 11.8-16). The median operative time was 120 min (IQR 116-134). All repairs were reinforced with permanent mesh. Sixty-eight percent of the patients (n = 17) were discharged on the same day. With a median follow-up of 30 days (IQR 16-107), 8% (n = 2) seromas, 16% (n = 4) developed clinically insignificant hematomas, and one patient (4%) developed ileus that was managed conservatively. CONCLUSION/CONCLUSIONS:This study establishes the feasibility and safety of R-PeTEP, which provides direct access to the preperitoneal space, avoiding disruption to the posterior rectus sheath, possibly reducing neurovascular bundle injuries, and omitting entry to the abdominal cavity. R-PeTEP facilitates wide flap creation for prosthetic overlap and allows for posterior plication of diastasis recti with little to no mesh fixation with overall excellent preliminary clinical outcomes.

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.