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: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.

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.

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.

BACKGROUND:The surgical management of midline ventral hernias complicated by concomitant diastasis recti presents a significant clinical challenge. The Endoscopic Onlay Repair (ENDOR) offers a minimally invasive solution, effectively addressing both conditions. This study focuses on describing the adaptation of ENDOR to a robotic platform, termed R-ENDOR, aiming to report initial outcomes along with other established robotic surgical approaches. METHODS:This retrospective case series study included consecutive adult patients who underwent R-ENDOR approach from October 2018 to April 2023, performed by a single surgeon. A comprehensive description of the surgical technique is included. Patient demographics, operative, and hernia-specific characteristics, as well as clinical outcomes are described. RESULTS:, with 20% (n = 3) classified as obese. Median hernia size was 2 cm (IQR 2-2.25), with a median diastasis length of 19 cm (IQR 15-21.5) and width of 4 cm (IQR 3-6). The median operative time was 129 min (IQR 113-166). Most repairs (93%, n = 14) were reinforced with mesh, predominantly self-fixating (73.3%, n = 11). Eighty percent of patients (n = 12) were discharged on the same day, with a median follow-up of 153 days (IQR 55-309). Notable complications included clinically significant seromas in 20% of patients (n = 3), long-term hypoesthesia in 40% (n = 6), and readmission in one patient (6.6%) for surgical site infection (SSI) requiring IV antibiotic therapy. CONCLUSION/CONCLUSIONS:Midline ventral hernias associated to diastasis recti can be managed robotically by ENDOR with safe and consistent 90-day outcomes in a carefully selected group of patients.

PURPOSE/OBJECTIVE: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/CONCLUSIONS: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.

Despite the paucity of evidence on robotic ventral hernia repair (RVHR) in patients with obesity, the robotic platform is being used more frequently in hernia surgery. The impact of obesity on RVHR outcomes has not been thoroughly studied. Obesity is considered a major risk factor for the development of recurrent ventral hernias and postoperative complications; however, we hypothesize that patients undergoing robotic repairs will have similar complication profiles despite their body mass index (BMI). We performed a retrospective analysis of patients aged 18-90 years who underwent RVHR between 2013 and 2023 using data from the Abdominal Core Health Quality Collaborative registry. Preoperative, intraoperative, and postoperative characteristics were compared in non-obese and obese groups, determined using a univariate and logistic regression analysis to compare short-term outcomes. The registry identified 9742 patients; 3666 were non-obese; 6076 were classified as obese (BMI > 30 kg/m²). There was an increased odds of surgical site occurrence in patients with obesity, mostly seroma formation; however, obesity was not a significant factor for a complication requiring a procedural intervention after RVHR. In contrast, the hernia-specific quality-of-life scores significantly improved following surgery for all patients, with those with obesity having more substantial improvement from baseline. Obesity does increase the risk of certain complications following RVHR in a BMI-dependent fashion; however, the odds of requiring a procedural intervention are not significantly increased by BMI. Patients with obesity have a significant improvement in their quality of life, and RVHR should be carefully considered in this population.