Faculty Bibliography

BACKGROUND:Patients presenting for evaluation of umbilical and epigastric hernias are often found to have diastasis recti (DR). As isolated hernia repair in these patients may be associated with higher rates of recurrence, prior international publications have described a prefascial mesh repair in combination with anterior plication of DR. We present our initial United States (US) experience with a SubCutaneous OnLay endoscopic Approach (SCOLA) to address these concurrent pathologies in a single hybrid procedure. METHODS:Between July 2018 and December 2019, a prospective cohort of 16 patients underwent the SCOLA procedure. Subcutaneous dissection was carried out from the suprapubic region superiorly to the xiphoid process and laterally to the linea semilunaris. Hernia contents were reduced and defects were incorporated into anterior DR plication, which was performed with running barbed suture. Onlay mesh was placed to cover the entire dissected space, and subcutaneous drains were placed. Three separate attendings performed cases with one supervising attending for standard technique. RESULTS:. The mean hernia defect size was 1.9 (0.7) cm. Mean operative time was 146 (46.3) minutes; two (15%) cases were performed robotically. The mean follow-up time was approximately two months (63 days). Three (18.8%) patients developed seroma, one (6.3%) patient developed an infected seroma, and two (12.5%) patients developed hernia recurrence. CONCLUSIONS:SCOLA technique is shown to be a safe and effective approach for patients presenting with small midline ventral hernias and concomitant DR. Our preliminary US data demonstrates higher rates of post-operative complication in patients with higher BMI, which suggests that patient selection and pre-operative counseling is essential to achieve better technical outcomes in our patient population.

BACKGROUND:A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different countries. The aim of this systematic review is to assess the safety and feasibility of different named techniques with the same surgical concept. METHODS:The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score system was used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study designs, risk of bias, publication bias, heterogeneity, and statistical analysis. RESULTS:The systematic literature search found 2548 articles, 317 of which were duplicates and excluded from analysis. The titles and abstracts from the remaining 2231 articles were assessed. After careful evaluation, 2125 articles were determined to be unrelated to our study and subsequently excluded. The full text of the remaining 106 articles was thoroughly assessed. Case reports, editorials, letters to the editor, and general reviews were then excluded. A total of 13 articles were ultimately included for this review, describing a similar subcutaneous endoscopic approach for repair of concomitant ventral hernias and rectus diastasis defined under nine different named techniques on 716 patients. The number of patients in those studies varied from 10 to 201. The mean operative time varied from 68.5 to 195 min. The most common complication was seroma, followed by pain requiring intervention, hematoma, and surgical site infection. CONCLUSIONS:There are a few technique variations described in different studies, but with no significant differences in outcomes. We, therefore, propose to unify these procedures under one term, ENDoscopic Onlay Repair (ENDOR). This technique has shown to be effective and safe, with seroma being the most common complication.

INTRODUCTION/BACKGROUND:In recent decades, minimally invasive approaches have found their place in treating a specific subset of patients with inguinal hernias, predominantly those with recurrent or bilateral disease. Classically, prior history of urologic pelvic operations, such as prostatectomy, has been listed as relative contraindication for minimally invasive inguinal hernia repair. As the adoption of the robotics platform continues to grow, we aim to outline a feasible robotic-assisted inguinal hernia repair technique in patients with previous prostatectomies. We report the outcomes of 15 patients who underwent repair at 2 institutions. METHODS:This is a retrospective case series of 15 patients who underwent robotic transabdominal preperitoneal approach repair of their inguinal hernias after prostatectomy. Demographics, intraoperative variables, and outcomes of our cases are described. RESULTS:Fifteen patients were included in our cohort. All patients had a history of prostatectomy (7 open, 2 laparoscopic, and 6 robotic) due to prostate cancer. Median age was 70 years old (range: 60 to 89 y), with a median body mass index of 26.3 kg/m2 (range: 20.5 to 37.4 kg/m2). Hernia defects were bilateral in 6 patients and unilateral in the remaining 9 (right; 6, left; 3). The shortest interval between prostatectomy and subsequent hernia repair was 4 months (range: 4 to 216 mo). The median operative time was 139 min (range: 91 to 281 min). All defects were repaired using a polypropylene mesh except in 1 case, where a coated monofilament polyester mesh was used after having a large peritoneal defect to close, preventing future adhesions to the bowel. Mesh sizes used were large (16×11 cm), extra-large (17×12 cm) for anatomic mesh, and 20×15 cm for the monofilament polyester mesh. The mesh was fixed in 14 of 15 cases. Fixation was accomplished with absorbable suture (n=13), barbed suture (n=1), and fibrin sealant (n=1). Peritoneal closure was always performed using a continuous running v-loc suture. There were no documented major intraoperative complications, no 30-day readmission, or recurrences recorded within the follow-up period. Postoperatively, only 2 seromas and 1 hematoma were documented during the follow-up period. CONCLUSIONS:Robotic inguinal hernia repairs in patients with previous prostatectomy is safe and feasible in most patients. Larger patient series are needed to confirm these findings.

INTRODUCTION AND IMPORTANCE/UNASSIGNED:Cecal bascule is a rare form of a cecal volvulus characterized by an anterior and superiorly displaced cecum in turn causing compression of the ascending colon that can result in a large bowel obstruction. We report a case of cecal bascule in a newly postpartum patient, with emphasis on clinical presentation, radiologic findings and treatment. CASE PRESENTATION/METHODS:A 37-year-old female who underwent an uncomplicated c-section and bilateral salpingectomy developed severe abdominal pain, vomiting, and peritonitis 12 h after surgery. A computerized tomography of the abdomen and pelvis revealed a dilated and superiorly displaced cecum. The diagnosis of cecal bascule was confirmed intraoperatively and a right hemicolectomy was performed. The patient recovered appropriately and was discharged on postoperative day six. DISCUSSION/CONCLUSIONS:Cecal bascule is the rarest form of cecal volvulus. In the context of obstetrics and gynecology, it has mostly been mentioned perioperatively after cesarean, but was also reported in an antepartum patient. It usually occurs in patients with redundant or mobile cecum, which is a result of incomplete fixation of the cecum to the retroperitoneum during embryogenesis. Other risk factors include recent surgery, previous abdominal surgery, ileus, chronic constipation, and distal colonic obstruction. An association has also been shown with pregnancy or the postpartum abdomen and is hypothesized to be due to mass effect. CONCLUSION/CONCLUSIONS:Cecal bascule is a serious entity requiring a high index of suspicion and warranting greater awareness in the post-natal patient. Clinical diagnosis, prompt imaging, and surgery are important to avoid bowel ischemia and perforation.

BACKGROUND:The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a widely performed minimally invasive operation, but can present considerable ergonomic challenges for the surgeon. Our objective was to determine if a novel handheld software-driven laparoscopic articulating needle driver can mitigate these difficulties. METHODS:The video recordings of a consecutive series of TAPP cases by a single surgeon using the articulating device were compared with a series of cases using straight-stick laparoscopy. Two critical steps of the procedure were analyzed for time: mesh fixation and peritoneal suture closure. These steps were then compared before and after 10 initial consecutive cases to analyze whether the surgeon demonstrated improvement. A cost analysis was also performed between the two techniques. RESULTS:For mesh fixation, the surgeon averaged 227 s using tacker devices, compared with 462.4 s using the novel laparoscopic device (p = 0.06). For the peritoneal closure component of the operation, the surgeon improved the time per suture pass during closure from 60.61 s during the first 10 cases to 38.84 s after the first 10 cases (p = 0.0004), which was comparable to the time per stitch for standard laparoscopy (34.8 s vs 34.84 s, p = 0.997). Left-sided inguinal hernia repairs using the articulating device demonstrated a significantly longer time per stitch during peritoneal closure compared to the right side after first 10 cases (left: 40.62 s; right: 27.91, p = 0.005). Our direct cost analysis demonstrated that suture closure of the peritoneum using the articulating device was more cost-effective than tack fixation. CONCLUSIONS:After only a 10 case initial experience, a laparoscopic hand-held articulating needle driver is comparable to standard laparoscopy to complete suture mesh fixation and peritoneal closure for TAPP inguinal hernia repair. Further, the feasibility of suture mesh fixation minimizes the need for costly tacker devices. This instrument appears to be a promising tool in this largely minimally invasive era of hernia repair.

PURPOSE/OBJECTIVE:To investigate risk factors for hernia recurrence, surgical site occurrence/infection (SSO/I) and those requiring procedural intervention (SSOPI) after incisional hernia repair (IHR) following abdominal transplantation. METHODS:Patients undergoing IHR following abdominal transplant were retrospectively identified in the Americas Hernia Society Quality Collaborative database. Primary outcome measures were SSO/I, SSOPI and hernia recurrence. RESULTS:was associated with 180-day recurrence, whereas history of hypertension remained significant for recurrence at 2 years (P < .05). CONCLUSION/CONCLUSIONS:History of an open abdomen, DM, and obesity are risk factors for SSO/I, and obesity and hypertension are associated with short-term and long-term recurrence after IHR following abdominal organ transplantation. Immunosuppression had negative correlation with SSO/I. However, long-term outcomes and those related to immunosuppression should be interpreted cautiously in view of the small sample size and low follow-up rates. Baseline comorbidities seem to be the main drive for hernia outcomes for transplant population, similar to the general population. Larger cohorts and longer follow-up are necessary to delineate preventable risk factors for SSO/Is and hernia recurrences after organ transplantation.

BACKGROUND:Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair. AIM/OBJECTIVE:To describe a robotic assisted surgical technique for incisional lumbar hernia repair. METHODS:Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies. RESULTS:Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGripTM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl® transfacial sutures, Evicel® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days. CONCLUSION/CONCLUSIONS:The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.

BACKGROUND:As the minimally invasive surgery revolution approaches 30 years, many techniques are now available for cholecystectomy: open, conventional laparoscopy, ini-laparoscopy, single incision, robotic, and natural orifice. Although much has been published about patient preferences regarding these techniques, less is known about surgeon perceptions and preferences. The aim of this study was to survey attending and trainee surgeons about which cholecystectomy technique they would prefer for themselves and what factors determine their decision. METHODS:Attending fellow and resident surgeons globally completed a Google Forms online questionnaire that was posted in 3 closed groups for surgeons on Facebook and WhatsApp. RESULTS:The online questionnaire was completed by 600 surgeons (453 attending surgeons and 147 residents/fellows). Most respondents were male individuals (87.6% of attending surgeons, 78.2% of trainee surgeons). The most common age range of respondents was 31 to 40 years. Surgeon response was global, with especially good representation from North American, Asian, and European physicians. When conventional laparoscopy, mini-laparoscopy, and robotic surgery were the options offered for cholecystectomy, 58.5% of trainees and 45.7% of surgeons chose conventional laparoscopy. When asked if they would consider a single-incision or natural orifice transluminal endoscopic surgery approach, 91.5% answered no. When asked which technique they would prefer if hypothetically all techniques were equally safe, about three-fourths chose either conventional laparoscopy (46%) or mini-laparoscopy (27%). When asked to rank which factors they considered most important in choosing a surgical technique, surgeon experience (52%) and safety of the procedure (45%) were the 2 most important factors. CONCLUSIONS:When an international sample of 600 attending and trainee surgeons were asked about undergoing a cholecystectomy on themselves, most chose either conventional laparoscopy or mini-laparoscopy as their preferred access technique. Single-incision and natural orifice transluminal endoscopic surgery approaches were unpopular. Surgeons ranked the experience of the operating surgeon and safety of the procedure as the most important factors guiding their decision.