Ergonomic differences in mesh placement and mesh fixation between laparoscopic and robotic inguinal hernia repair with mesh.

PURPOSE: General differences in surgeon ergonomics between laparoscopic and robotic-assisted inguinal hernia repairs (LIHR vs. RIHR) have been previously studied. However, specific differences in the ergonomics of mesh placement (MP) and mesh fixation (MF) are undetermined. Our aim was to determine if there are differences in the ergonomics of MP and MF between the surgical approaches. We hypothesize that we will identify differences, with the potential for worse ergonomics during LIHR. METHODS: Data was collected from fifteen LIHR and fifteen RIHR. All cases were elective, primary inguinal hernias completed by a fellowship-trained minimally invasive surgeon. Surface electromyography (EMG) of four upper extremity muscle groups, including the upper trapezius (UT), anterior deltoid (AD), flexor carpi radialis (FCR) and extensor digitorum (ED), was recorded bilaterally during MP and MF. Muscle activation as a percent of maximum voluntary contraction (%MVCRMS) and muscle fatigue denoted as the median frequency of muscle activations (Fmed) were calculated for each muscle. RESULTS: EMG analysis showed increased %MVCRMS in LIHR compared to RIHR cases, with significant findings in the left UT, right UT, ED, and FCR for MP and MF and the left FCR during MP. Muscle fatigue was decreased in LIHR compared to RIHR cases, with significant differences in left FCR and right ED and AD. CONCLUSION: Despite greater muscle activations during LIHR, RIHR had greater muscle fatigue. It is possible that short periods of high muscle activation are ergonomically protective during minimally invasive inguinal hernia repair. Identifying these differences may aid in development of procedure-specific interventions to improve ergonomics.

Association of changes in HerQLes scores with objective hernia outcomes: an analysis of the ACHQC database.

BACKGROUND: There are both objective and subjective measures of success following ventral hernia repair (VHR). Using the Abdominal Core Health Quality Collaborative (ACHQC) database, we sought to determine if there is an association between 30-day wound events (objective) and changes in the hernia-related quality-of-life (HerQLes) scores, (subjective). We hypothesized that patients who do not experience a 30-day wound event have a greater improvement in their HerQLes score over the short-term. METHODS: All adult patients who underwent VHR with 30-day follow-up data available between 2013 and 2022 were identified within the ACHQC database. The 30-day wound events included surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI). The association between 30-day wound events and changes in HerQLes scores was measured using propensity matched score analysis. Further, regression analysis was used to determine if an improvement in HerQLes score at 30-days postoperatively was associated with the likelihood of experiencing a 30-day wound event. RESULTS: Following a 3:1 matched analysis, 17,796 patients were available for analysis; 4449 (25%) patients experienced a 30-day wound event. The most common SSI was a superficial SSI and the most common SSO was a seroma. A 10-point improvement in the HerQLes score was statistically associated with a 3% decrease in SSI and a 4% decrease in the odds of experiencing an SSO. While not statistically significant, a 10-point improvement in the HerQLes score was associated with a 2.4% decrease in the odds of experiencing an SSOPI. CONCLUSIONS: Subjective and objective measures of success following VHR seem to be correlated with one another over the short-term. Additional studies are needed to determine if this correlation exists with other subjective and objective measures of success and to determine if these correlations persist over the long-term. If present, these associations may help to guide patient counseling as experiencing a postoperative wound event following ventral hernia repair may not be detrimental to their quality-of-life over the long-term.

Phosphorylation status of fetuin-A is critical for inhibition of insulin action and is correlated with obesity and insulin resistance.

Fetuin-A (Fet-A), a hepatokine associated with insulin resistance, obesity, and incident type 2 diabetes, is shown to exist in both phosphorylated and dephosphorylated forms in circulation. However, studies on fetuin-A phosphorylation status in insulin-resistant conditions and its functional significance are limited. We demonstrate that serum phosphofetuin-A (Ser312) levels were significantly elevated in high-fat diet-induced obese mice, insulin-resistant Zucker diabetic fatty rats, and in individuals with obesity who are insulin resistant. Unlike serum total fetuin-A, serum phosphofetuin-A was associated with body weight, insulin, and markers of insulin resistance. To characterize potential mechanisms, fetuin-A was purified from Hep3B human hepatoma cells. Hep3B Fet-A was phosphorylated (Ser312) and inhibited insulin-stimulated glucose uptake and glycogen synthesis in L6GLUT4 myoblasts. Furthermore, single (Ser312Ala) and double (Ser312Ala + Ser120Ala) phosphorylation-defective Fet-A mutants were without effect on glucose uptake and glycogen synthesis in L6GLUT4 myoblasts. Together, our studies demonstrate that phosphorylation status of Fet-A (Ser312) is associated with obesity and insulin resistance and raise the possibility that Fet-A phosphorylation may play a role in regulation of insulin action.

How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia.

BACKGROUND: Robotic techniques are routinely used in urological and gynecological procedures; however, their role in general surgical procedures is limited. A robotic technique has been successfully adopted for a minimally invasive Heller myotomy procedure for achalasia. This study aims to compare perioperative outcomes following open, laparoscopic, and robotic Heller myotomy. METHODS: This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium (UHC) is an alliance between academic medical centers and affiliate hospitals. The UHC database was accessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes and analyzed. RESULTS: 2,683 patients with achalasia underwent Heller myotomy between October 2007 and June 2011. Myotomy was performed by open surgery (OM) in 418 patients, by laparoscopic approach (LM) in 2,116, and by robotic approach (RM) in 149. Comparison between LM and RM groups demonstrated no significant difference in mortality (0.14 vs. 0.0%; P = 1), morbidity (5.19 vs. 4.02%; P = 0.7), intensive care unit (ICU) admission (6.62 vs. 3.36%; P = 0.12), length of stay (LOS) (2.70 ± 3.87 days vs. 2.42 ± 2.69 days; P = 0.34), or 30-day readmission (1.41 vs. 2.84%; P = 0.27). However, hospital costs were significantly lower for the LM group (US $7,441 ± 7,897 vs. US $9,415 ± 5,515; P = 0.0028). Comparison between OM and RM demonstrated significant lower morbidity (9.08 vs. 4.02%; P = 0.02), ICU admission rate (14.01 vs. 3.36%, P = 0.0002), and LOS (4.42 ± 5.25 days vs. 2.42 ± 2.69 days; P = 0.0001). CONCLUSIONS: The perioperative outcomes are superior in LM and RM groups when compared with OM. The outcomes for the LM and RM group are comparable, with the robotic group having slightly improved results, although with increased costs. We conclude that robotic surgery is equivalent in safety and efficacy to laparoscopic Heller myotomy, and feel that the increased cost should come down as surgeons and manufacturers work together on cost reduction strategies.