A feasible procedure for laparoscopic cesarean scar defect repair.

In 1995, Morris first described cesarean scar defect (CSD) as an "isthmocele" by macroscopy following hysterectomy in women with a prior cesarean delivery. CSD is associated with gynecological symptoms such as abnormal uterine bleeding (AUB), secondary infertility, pelvic pain, and obstetrical complications such as cesarean scar pregnancy, placenta accreta, and uterine rupture. Surgical treatment techniques include hysteroscopic resection, transabdominal repair (laparotomy, laparoscopic, and robotic), and vaginal repair. If the residual myometrial thickness is <3 mm and the patient is symptomatic, consideration is made for defect repair laparoscopically rather than hysteroscopic resection. The advantages of laparoscopic repair include anatomic restoration of myometrial thickness, correction of uterine retroflexion, exploration of other causes of infertility and pelvic pain, and pathological diagnosis of scar tissue with endometriosis. CSD often cannot be visualized from the abdominal cavity; therefore, it is difficult to identify the extent of the defect laparoscopically. Herein, we introduce laparoscopic CSD repair through a surgical video with narration (Video 1). This technique uses a uterine manipulator to distend and help delineate the defect, and a laparoscopic support suture within the defect as a "handle" to place the scar tissue on tension to ensure complete resection of the fibrotic tissue. Temporary uterine artery occlusion can be included to reduce bleeding in the surgical field to support visualization for complete fibrotic tissue removal and to achieve good apposition with a double-layer suture to promote proper anatomic wound healing. Symptom relief was achieved, and the patient became pregnant one year postoperatively. This video demonstrated a feasible, safe, effective procedure for laparoscopic CSD repair in the patient.

Comparison between the open and the laparoscopic approach in the primary ventral hernia repair: a systematic review and meta-analysis.

BACKGROUND: Ventral hernia repair underwent various developments in the previous decade. Laparoscopic primary ventral hernia repair may be an alternative to open repair since it prevents large abdominal incisions. However, whether laparoscopy improves clinical outcomes has not been systematically assessed. OBJECTIVES: The aim is to compare the clinical outcomes of the laparoscopic versus open approach of primary ventral hernias. METHODS: A systematic search of MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted in February 2023. All randomized controlled trials comparing laparoscopy with the open approach in patients with a primary ventral hernia were included. A fixed-effects meta-analysis of risk ratios was performed for hernia recurrence, local infection, wound dehiscence, and local seroma. Meta-analysis for weighted mean differences was performed for postoperative pain, duration of surgery, length of hospital stay, and time until return to work. RESULTS: Nine studies were included in the systematic review and meta-analysis. The overall hernia recurrence was twice less likely to occur in laparoscopy (RR = 0.49; 95%CI = 0.32-0.74; p < 0.001; I2 = 29%). Local infection (RR = 0.30; 95%CI = 0.19-0.49; p < 0.001; I2 = 0%), wound dehiscence (RR = 0.08; 95%CI = 0.02-0.32; p < 0.001; I2 = 0%), and local seroma (RR = 0.34; 95%CI = 0.19-0.59; p < 0.001; I2 = 14%) were also significantly less likely in patients undergoing laparoscopy. Severe heterogeneity was obtained when pooling data on postoperative pain, duration of surgery, length of hospital stay, and time until return to work. CONCLUSION: The results of available studies are controversial and have a high risk of bias, small sample sizes, and no well-defined protocols. However, the laparoscopic approach seems associated with a lower frequency of hernia recurrence, local infection, wound dehiscence, and local seroma.

Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis.

INTRODUCTION: Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes. METHODS: We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality. RESULTS: Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.

Varying convalescence recommendations for sport and heavy lifting after groin hernia repair: a nationwide survey among leading hernia surgeons.

BACKGROUND: Recent international hernia guidelines state that work and leisure activities after inguinal hernia repair can be resumed after a convalescence of three to five days for most patients. There is no specific recommendation for convalescence duration before resuming sport and heavy lifting. This nationwide survey aimed to assess leading hernia surgeons' recommendations for convalescence after groin hernia repair and to explore their general opinions regarding convalescence. METHODS: A validated questionnaire was sent to 32 leading groin hernia surgeons covering all Danish private and public hospitals. The primary outcome was convalescence recommendations following Lichtenstein and laparoscopic groin hernia repair for activities of daily living, light work, sport, and heavy lifting. RESULTS: A total of 29 surgeons (91%) responded to the questionnaire. The surgeons generally agreed on resuming daily activities and light work as soon as possible according to the level of pain. For resumption of sport, the surgeons recommended a median convalescence of 14 days (IQR 10-23, range 7-30) after Lichtenstein repair and 14 days (IQR 10-21, range 7-30) after laparoscopic repair. Most of the surgeons instructed patients with a defined number of days before resuming heavy lifting, which after Lichtenstein repair was median 14 days (IQR 8-28, range 2-30) and after laparoscopic repair was median 21 days (IQR 14-30, range 7-30). None of the surgeons routinely prescribed sick leave. Seventeen surgeons (61%) thought that recommending a too short convalescence could cause complications, primarily recurrence, hematoma, and pain. CONCLUSION: This study revealed that surgeons agreed on the resumption of daily activities and light work as soon as possible according to the level of pain. However, a broad spectrum of convalescence recommendations was revealed for sport and heavy lifting.

The INCH-trial: a multicenter randomized controlled trial comparing short- and long-term outcomes of open and laparoscopic surgery for incisional hernia repair.

BACKGROUND: Laparoscopic incisional hernia repair is increasingly performed worldwide and expected to be superior to conventional open repair regarding hospital stay and quality of life (QoL). The INCisional Hernia-Trial was designed to test this hypothesis. METHODS: A multicenter parallel randomized controlled open-label trial with a superiority design was conducted in six hospitals in the Netherlands. Patients with primary or recurrent incisional hernias were randomized by computer-guided block-randomization to undergo either conventional open or laparoscopic repair. Primary endpoint was postoperative length of hospital stay in days. Secondary endpoints included QoL, complications, and recurrences. Patients were followed up for at least 5 years. RESULTS: Hundred-and-two patients were recruited and randomized. In total, 88 patients underwent surgery and were included in the intention-to-treat analysis (44 in the open group, 44 in the laparoscopic group). Mean age was 59.5 years, gender division was equal, and BMI was 28.8 kg/m. The trial was concluded early for futility after an unplanned interim analysis, which showed that the hypothesis needed to be rejected. There was no difference in primary outcome: length of hospital stay was 3 (range 1-36) days in the open group and 3 (range 1-12) days in the laparoscopic group (p = 0.481). There were no significant between-group differences in QoL questionnaires on the short and long term. Satisfaction was impaired in the open group. Overall recurrence rate was 19%, of which 16% in the open and 23% in the laparoscopic group (p = 0.25) at a mean follow-up of 6.6 years. CONCLUSIONS: In a randomized controlled trial, short- and long-term outcomes after laparoscopic incisional hernia repair were not superior to open surgery. The persisting high recurrence rates, reduced QoL, and suboptimal satisfaction warrant the need for patient's expectation management in the preoperative process and individualized surgical management. TRIAL REGISTRATION: Netherlands Trial Register NTR2808.

Laparoscopic inguinal hernia repair: impact of surgical time in the learning curve.

PURPOSE: One of the procedures that has become very popular thanks to the advantages of minimally invasive approach is the laparoscopic treatment of inguinocrural hernias. As a disadvantage, it would imply a longer learning curve when compared to the conventional approach. There is no consensus about the number of procedures required to dominate this surgical technique, since according to bibliography it ranges from 20 to 240. METHODS: We analyzed and compared the progress of 18 third year surgical residents while they were introducing into laparoscopic transabdominal preperitoneal inguinal hernioplasties between June 2013 and May 2018. RESULTS: Between June 2013 and May 2018, 1282 laparoscopic inguinal hernioplasties were performed (71 procedures per resident). Mean surgical time was for unilateral: 62.13 min (SD ± 15.54; range 30-105 min) for the first third (Q1) vs 54.61 min (SD ± 15.38; range 30-100 min) for the last third (Q3): p < 0.0001. For bilateral were: 92.59 min (SD ± 21.89; range 50-160 min) for Q1 vs 84.48 min (SD ± 20.52; range 30-130 min) for Q3: p < 0.05. Accepting an alpha error of 5% and considering an association power of 80%, there would be needed 61 cases per surgeon to achieve a significant reduction in surgical time. CONCLUSION: In a center with high-volume in TAPP and under a supervised training program, it is feasible to achieve a reduction in surgical time. Randomized studies with a larger number of cases are necessary to confirm this finding and draw more robust and objective conclusions.

Comparison of mesh fixation and non-fixation in transabdominal preperitoneal (TAPP) inguinal hernia repair: a randomized control trial.

INTRODUCTION: Mesh fixation in inguinal hernia repair, has been a controversial subject for many years. Therefore, in this study, we evaluated and compared fixation and non-fixation of mesh in Transabdominal Preperitoneal (TAPP) Inguinal hernia repair. METHODS: In this randomized control trial, 100 patients diagnosed with unilateral inguinal hernia were included. We divided the study population into two groups of fifty. For both groups, a 15 × 13 cm Prolene(polypropylene) mesh was used for repair. In the fixation group, mesh was fixed to the abdominal wall by endoscopic tacks, while in the non-fixation group, mesh was secured at the proper place without any fixation. Postoperative outcomes were complications, recurrence, and pain intensity after 1-, 3- and 6-months. RESULTS: Postoperative pain intensity in the 1st month [Median of 2 and 0, (P < 0.001)], and 3rd month [Median of 0.5 and 0, (P < 0.001)], in the fixation group were significantly higher than the non-fixation group. However, 6 months after surgery, pain intensity was almost similar for both groups. In the 6th postoperative month, only one patient experienced recurrence who was in the fixation group. The rate of recurrence and urinary retention between the groups was not significant. CONCLUSION: It was observed that until 6 months after surgery patients who received the non-fixating method of TAPP repair experienced lower levels of pain in comparison to the fixation group while other complications did not differ between the two groups. This trail was registered at www.irct.ir with Trial Registration Number of IRCT20210224050491N1.

Outcomes of laparoscopic modified Cellan-Jones repair versus open repair for perforated peptic ulcer at a community hospital.

INTRODUCTION: Minimally invasive or open Graham Patch repair remains the gold standard approach for management of perforated peptic ulcers (PPU). Herein, we report outcomes of laparoscopic technique and compare it with open approach at a community hospital. METHODS: Retrospective observational study conducted comparing laparoscopic modified Cellan-Jones repair (mCJR) versus the standard open repair of PPU. Patients aged 18-90 years during 2016-2021 were offered either a minimally invasive or open approach depending on surgeon laparoscopic capability, and were compared in terms of demographics, co-morbidities, intra-operative details, and short-term outcomes. RESULTS: A total of 49 patients were included (46.9% males, mean age 52.9 years, mean BMI 25.0, ASA ≥ III 75.5%, 75.5% smokers, 26.5% current NSAIDs use, and 71.4% alcohol drinkers). Duodenum was the most common perforation site (57.1%), and majority of ulcers were 1-2 cm (72.9%). Laparoscopic approach was performed in 16 consecutive patients (32.7%) by a single surgeon, with no conversions. Preoperative characteristics were similar for both groups. Compared to open approach, laparoscopic group were taken to operation immediately (< 4 h) (87.5% vs. 15.2%, p < 0.001), had lower estimated blood loss (11.8 ml vs. 73.8 ml, p = 0.063), and longer operative time (117.1 min vs. 85.6 min, p = 0.010). Postoperatively, nasogastric tube was removed earlier in laparoscopic group (POD1-2, 87.5% vs. 24.2%, p = 0.001), with earlier resumption of diet (POD1-2, 62.6% vs. 9.1%, p = 0.002), less narcotic usage (< 3 days, 58.3% vs. 6.1%, p < 0.001), earlier return of bowel function (POD1-2, 43.8% vs. 9.1%, p = 0.003) and shorter length of stay (LOS) (3.7 days vs. 16.1 days, p < 0.001). Both in-house mortality and morbidity rates were lower in the laparoscopic group, but not statistically significant [(0% vs. 6.1%, p = 0.347) and (12.5% vs. 39.4%, p = 0.500), respectively]. CONCLUSION: Laparoscopic mCJR is a feasible method for repair of PPU, and it is associated with shorter LOS, and less narcotics usage in comparison to the open repair approach.

Laparoscopic transabdominal preperitoneal repair for female patients with groin hernias.

BACKGROUND: Laparoscopic transabdominal preperitoneal repair (TAPP) was recommended for female patients with groin hernias. Whereas, only a few studies focused on whether and how to preserve the round ligament of the uterus in TAPP. METHODS: Clinical data of 159 female patients with 181 groin hernias who underwent TAPP at a single institution in China from January 2016 to June 2022 were retrospectively reviewed and collected. RESULTS: All the patients underwent the operation smoothly without conversion. Division of the round ligament was performed for 33 hernias. Preservation of the round ligament was adopted for 148 hernias, 51 with the "keyhole" technique, 86 with the "longitudinal incision of peritoneum" method, and 11 with total dissection of the round ligament. The mean operative time was 55.6 ± 8.7 min for unilateral TAPP and 99.1 ± 15.8 min for bilateral TAPP. The mean estimated blood loss was 7.1 ± 4.5 mL. The postoperative complications included 6 (3.3%) cases of seroma, 1 (0.5%) case of hematoma, and 3 (1.6%) cases of mild chronic pain. The incidences of chronic pelvic pain and genital prolapse seemed to be higher in the division group than in the preservation groups (6.1% vs. 0.6% and 3.0% vs. 0%, separately). However, no statistical difference was observed (p > 0.05). CONCLUSIONS: TAPP is feasible and effective for female patients with groin hernias, especially in preserving the round ligament of the uterus.

Efficacy of a modified needle grasper for single-port laparoscopic hernia repair in children: a propensity score-matched analysis.

PURPOSE: The advantage of using the single-port technique over the conventional two-port approach is uncertain. This study aimed to evaluate the outcomes of a single-port laparoscopic percutaneous extraperitoneal closure (SLPEC) using a modified needle grasper in children and compare the results to those of two-port laparoscopic percutaneous extraperitoneal closure (TLPEC). METHODS: A retrospective cohort analysis of SLPEC and TLPEC surgery from February 2016 to June 2021 was conducted at our institution. Pediatric patients underwent SLPEC using the modified needle grasper to complete the high ligation of the hernia sac, while operations in the conventional two-port group only used regular laparoscopic instruments. A 1:1 propensity score matching (PSM) analysis was used to reduce selection bias. RESULTS: Of 1320 patients, 1169 were included in the single-port/two-port crude evaluation, with 930 in the PSM cohort (465 patients/arm). Among 1:1 matched patients, the operation time for single-port patients vs. two-port patients were 11.28 ± 3.98 vs. 15.47 ± 4.54 min for unilateral repair and 16.86 ± 4.59 vs. 20.40 ± 4.29 min for bilateral repair (p < .05). Cosmetic results did not differ between the SLPEC and TLPEC groups (0% vs. 0.7%, p = 0.249). The recurrence rates were comparable between the two groups (0.6% vs. 1.1%, p = 0.725). Moreover, the differences in surgical site infection (SSI), testicular atrophy, open conversion and postoperative hydrocele occurrence were insignificant between the two groups. CONCLUSIONS: In this cohort study, the modified needle grasper is a safe and feasible instrument for SLPEC, and SLPEC using the needle grasper has a shorter operation time than TLPEC.

Robotic versus hybrid assisted ventral hernia repair: a prospective one-year comparative study of clinical outcomes.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) may be associated with chronic pain, seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence and poor quality of life (QoL). Our study evaluates whether robotic-assisted ventral hernia repair (rVHR) diminishes these complications compared to LVHR with primary closure of the defect (hybrid). METHODS: Thirty-eight consecutive patients undergoing incisional ventral hernia operation with fascial defect size from 3 to 6 cm were recruited between November 2019 and October 2020. Nineteen patients underwent rVHR and nineteen underwent hybrid operation. The main outcome measure was postoperative pain, evaluated with a visual analogue scale (VAS: 0-10) at 1-month and at 1-year. Hernia recurrence was evaluated with ultrasound examination and QoL using the generic SF-36 short form questionnaire. RESULTS: At the 1-month control visit, VAS scores were significantly lower in the rVHR group; 2.5 in the hybrid group and 0.3 in the rVHR group (p < 0.001). At the 1-year control, the difference in VAS scores was still significant, 2.8 vs 0.1 (p = 0.023). There was one hernia recurrence in the hybrid group (p = 0.331). QoL did not differ significantly between the study groups when compared to preoperative physical status at 1-year follow-up (p = 0.121). However, emotional status (p = 0.049) and social functioning (p = 0.039) improved significantly in the rVHR group. CONCLUSIONS: Robotic-assisted ventral hernia repair (rVHR) was less painful compared to hybrid repair at 1-month and at 1-year follow-up. In addition, improvement in social functioning status was reported with rVHR. TRIAL REGISTRATION ID: 5200658.

Laparoscopic management of symptomatic congenital diaphragmatic hernia of Morgagni in the adult.

BACKGROUND: Currently, there is a relative paucity of literature regarding the management of symptomatic congenital diaphragmatic hernia of the foramen of Morgagni in the adult. This study aims to describe our unique surgical technique and outcomes in adult patients undergoing laparoscopic repair of symptomatic Morgagni hernia. METHODS: This is a retrospective review of adult patients from 2003 to 2020 who underwent a laparoscopic Morgagni hernia repair at our institution. All patients underwent a similar laparoscopic approach, utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect and mesh reinforcement with permanent mesh if the primary repair was subjectively under tension. RESULTS: The study population consisted of 12 consecutive patients with a Morgagni hernia. Patients presented with a variety of symptoms attributed to the hernia, including pain 83% (n = 10), respiratory symptoms and shortness of breath 58% (7), and gastrointestinal obstruction 25% (3). Other complaints included: nausea 33% (4), reflux 50% (6), early satiety 8% (1), palpitations 16% (2), a gurgling sensation in the chest 8% (1), and weight loss 8% (1). Primary repair was possible in all patients following complete reduction of hernia contents including the hernia sac. Mesh reinforcement was used in 5 of 12 patients. Average surgical operative time was 93 (± 37) min. Median length of stay was 1.3 days (range 0.5-5.5 days). At a median follow-up of 10.9 months (IQR 8.0-41.5 months), all symptoms attributed to the hernia had resolved. No recurrences were identified. CONCLUSIONS: Adults with symptomatic Morgagni hernia should undergo surgical repair. A laparoscopic approach utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect (when possible), with or without mesh reinforcement can be performed safely and effectively.

Open versus laparoscopic repair of inguinal hernia: an overview of systematic reviews of randomised controlled trials.

BACKGROUND: Inguinal hernia has a lifetime incidence of 27% in men and 3% in women. Surgery is the recommended treatment, but there is no consensus on the best method. Open repair is most popular, but there are concerns about the risk of chronic groin pain. Laparoscopic repair is increasingly accepted due to the lower risk of chronic pain, although its recurrence rate is still unclear. The aim of this overview is to compare the risk of recurrence and chronic groin pain in laparoscopic versus open repair for inguinal hernia. METHODS: We searched Ovid MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for systematic reviews and meta-analyses. Only reviews of randomised controlled trials (RCTs) in adults published in English were included. Conference proceedings and editorials were excluded. The quality of the systematic reviews was assessed using the AMSTAR 2 checklist. Two outcomes were considered: hernia recurrence and chronic pain. RESULTS: Twenty-one systematic reviews and meta-analyses were included. Laparoscopic repair was associated with a lower risk of chronic groin pain compared with open repair. In the four systematic reviews assessing any laparoscopic versus any open repairs, laparoscopic repair was associated with a statistically significant (range: 26-46%) reduction in the odds or risk of chronic pain. Most reviews showed no difference in recurrence rates between laparoscopic and open repairs, regardless of the types of repair considered or the types of hernia that were studied, but most reviews had wide confidence intervals and we cannot rule out clinically important effects favouring either type of repair. CONCLUSION: Meta-analyses suggest that laparoscopic repairs have a lower incidence of chronic groin pain than open repair, but there is no evidence of differences in recurrence rates between laparoscopic and open repairs.

Laparoscopic Umbilical Hernia repair in male patients with abdominal obesity.

Objective: Obesity is a global health problem, and obese patients are subject to developing abdominal wall hernias. There are few prospective studies comparing the laparoscopic method of umbilical hernia mesh repair between abdominal obesity patients and normal abdominal waist patients. The aim of this study was to evaluate the short-term outcomes (operative time, early complications and hospital stay) in the patients having laparoscopic hernia repair with abdominal obesity. Methods: This prospective cohort study was conducted at King Fahad Hospital Hofuf, Kingdom of Saudi Arabia from June 2014 to June 2021. Fifty four (54) adult male patients with umbilical hernia were included in this study. The patients were divided into two groups: Group-A: Patients with abdominal obesity (n=26), and Group-B: Patients without abdominal obesity (n=28). All the patients underwent laparoscopic repair of umbilical hernia. The patients with abdominal obesity were defined as those having an abdominal girth more than 102 centimeters. Results: No significant differences were observed as related to age, co-morbidity and risk factors between the two groups. The statistically significant difference between the two groups observed was related to the mean operative time and the mean hospital stay. Conclusion: Laparoscopic umbilical hernia repair can be safely performed in abdominal obesity in male patients without an additional risk of complications.

Laparoscopic repair of perforated peptic ulcer - routine procedure or targeted patient selection?

INTRODUCTION: Peptic ulcer is one of the most common diseases of the proximal gastrointestinal tract. Its complications are relatively common, the most serious one being peptic ulcer perforation with the incidence of about 10 cases per 100,000 population per year and the mortality rate of 10-40%. Surgical suture via laparoscopy or laparotomy is the only treatment option. The aim of the study was to compare the short-term results of laparoscopic and open repair of acute peptic ulcer perforation and evaluate the accuracy of the Boey scoring system in the Czech population. METHODS: Retrospective study conducted at the surgical department of the University Hospital Ostrava. The patients underwent laparoscopic or open repair of perforated peptic ulcer in 2017-2021. RESULTS: The study included 60 patients; laparoscopic repair was performed in 43.3% of the patients, and open repair in 56.7%. Postoperative morbidity was 70.0%, mild complications were reported in 23.3% of the patients, and severe complications in 16.7%. Patients undergoing the laparoscopic repair showed a higher incidence of mild as well as severe complications (26.9% vs 20.6% and 19.2% vs 14.7%) but also a higher incidence of an uncomplicated postoperative course. Overall postoperative mortality was 30.0% (laparoscopy 15.4%, laparotomy 41.2%). The study results confirmed the estimated baseline risk of mortality based on the Boey score. CONCLUSION: Laparoscopic repair may be the procedure of choice for patients with no or low risk factors. Patients undergoing laparoscopy showed a higher incidence of mild and severe complications. The higher mortality of patients after open repair is related to their worse initial clinical condition. Preoperative determination of mortality risk using the Boey score is accurate and appropriate in terms of choosing the surgical approach.

Outcomes of Laparoscopic vs Open Repair of Perforated Peptic Ulcers: An ACS-NSQIP Study.

BACKGROUND: Perforated peptic ulcer (PPU) is a surgical emergency needing swift operative resolution. While laparoscopic and open approaches are viable options, it remains unclear whether laparoscopic repair has significantly improved outcomes. We use a national surgical database to compare perioperative and 30-d postoperative (30POP) outcomes. MATERIALS AND METHODS: The 2016-2018 ACS-NSQIP database was used to create the patient cohort, using ICD-10 and CPT codes. An unmatched analysis identified factors that likely contributed to the laparoscopic versus open treatment allocation. Propensity score matching (PSM) was used to identify outcomes that were not explained by underlying differences in the patient cohorts. RESULTS: A total of 3475 patients were included: 3135 in open group (OG), 340 (~10%) in laparoscopic group (LG). After PSM to control for comorbidities and illness severity that differed between groups on univariate analysis, 288 patients remained in each group. Analysis of the matched cohorts revealed no statistically significant difference in mortality (5.9% OG versus 3.8% LG, P = 0.245). The LG had significantly longer operative times (92 versus 79 min, P = 0.003), shorter hospital stays (8.2 versus 9.4 d, P = 0.044) and higher probability of being discharged home (81% versus 73%, P = 0.017). 30POP outcomes were largely equivalent, except that OG had higher risk for bleeding (14.6% versus 8%, P = 0.012) and pneumonia (8.7% versus 4.5%, P = 0.044). CONCLUSIONS: While laparoscopic repairs take longer, they lead to shorter hospital stays and higher likelihood of discharge home. Further study to identify patients that are candidates for this technique is warranted.

Open Versus Laparoscopic Repair of Traumatic Diaphragmatic Injury: A Nationwide Propensity-Matched Analysis.

INTRODUCTION: Minimally invasive surgical techniques have become routinely applied in the evaluation and treatment of patients with isolated traumatic diaphragmatic injuries (TDI). However, there remains a paucity of data that compares the laparoscopic repair to the open repair approach. The aim of our study is to examine patient outcomes between TDI patients managed laparoscopically versus those managed using open repair. METHODS: Adult (age ≥18 years) trauma patients presenting with TDI that required surgical repair were identified in the Trauma Quality Improvement Program database 2017. Patients were excluded if they underwent any other surgical procedure of the abdomen or chest. Patients were then stratified into 2 groups based on the surgical approach: laparoscopic repair of the diaphragm versus open repair. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were in-hospital major complications and length of stay (LOS). Secondary outcome measure was in-hospital mortality. RESULTS: A total of 177 adult trauma patients who had a laparoscopic repair of their isolated diaphragmatic injury were matched to 354 patients who had an open repair. Mean age was 35 ± 16 years, 78% were male, and mean BMI was 27 ± 7 kg/m2. 67 percent of the patients had penetrating injuries, and the median ISS was 17 [9-21]. CT imaging was done in 67% of the patients, with 71% presenting with left-sided injury and 21% having visceral herniation. Conversion from laparoscopic to open was reported in 7.3% of the cases. Patients with a laparoscopic repair had significantly lower rates of major complications (5.6 versus 14.4%; P<0.001), shorter hospital LOS (6 [3-9] versus 9 [5-13] days; P<0.001) and ICU LOS (3 [2-7] versus 5 [2-10] days; P<0.001). No difference was found in rates of in-hospital mortality (0.6 versuss 2.0%; P = 0.129) between the 2 groups. CONCLUSION: Laparoscopic repair of traumatic diaphragmatic injury was associated with decreased morbidity and a shorter hospital course, with a low conversion rate to open repair. Future studies remain necessary to further explore the long-term outcomes of patients with such injury. LEVEL OF EVIDENCE: Level III STUDY TYPE: Therapeutic.

Laparoscopic totally extraperitoneal and transabdominal preperitoneal approaches are equally effective for spigelian hernia repair.

INTRODUCTION: Spigelian hernias (SH) are rare intraparietal abdominal wall hernias occurring just medial to the semilunar line. Several small series have reported on laparoscopic SH repair and both totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches have been described. However, there are limited outcome data including both of these techniques. We present the largest series to date of laparoscopic SH repair comparing both popular approaches. METHODS: Consecutive patients (n = 77) undergoing laparoscopic SH repair from 2009 to 2019 were identified from a prospectively managed quality database. All procedures were performed at a single institution. Patients were divided based on laparoscopic approach used, TEP group (n = 37) and TAPP group (n = 40). Comparison of patient demographics, surgical characteristics, and post-operative complications between TAPP and TEP groups was made using the Wilcoxon rank-sum and Fisher's exact tests. RESULTS: Individuals undergoing TAPP had higher mean BMI (29.3 ± 5.4 vs. 26.3 ± 5.6 kg/m2; p = 0.019) and were more likely to have had prior abdominal surgery (65% vs 24.3%, (p < 0.001). Mean procedure length was 77 ± 45 min for TAPP repairs and 48 ± 21 for TEP repairs (p = 0.001). TAPP repairs had a significantly longer median LOS than TEP (25 vs. 7 h; p < 0.001). Days of narcotic use were significantly shorter after TEP repair than for TAPP (0 vs. 3; p = 0.007) and return to ADL was significantly shorter after TEP repair than for TAPP (5 vs. 7 days; p = 0.016. There were no significant differences in readmission, reoperations, SSI, or recurrence between the two groups. CONCLUSION: Our large series revealed that both preperitoneal laparoscopic approaches, TEP, and TAPP, for SH repair are equally safe, effective, and can be performed on an outpatient basis. Therefore, we suggest that the approach used for repair should be based on surgeon experience, preference, and individual patient factors.

Short-term quality of life comparison of laparoscopic, open, and robotic incisional hernia repairs.

BACKGROUND: Outcomes of incisional hernia repair (IHR) include recurrence and quality of life (QOL). Operative approaches include laparoscopic, open, and robotic approaches. Data regarding comparative QOL outcomes among these repair types are unknown. Our study evaluates quality of life after three approaches to IHR. STUDY DESIGN: Patients undergoing open (OHR), laparoscopic (LIHR), and robotic extra-peritoneal (RIHR) at a single institution from 2009 to 2019 were reviewed from a prospectively managed quality database. Short-term QOL was compared among the three procedures using the Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CCS), objective pain scores and postoperative narcotic use. Data regarding length of stay (LOS), emergency department (ED) visits, readmission, reoperations and surgical site infection (SSI) were also collected. RESULTS: A total of 795 patients undergoing IHR were analyzed (418 open, 300 laparoscopic and 77 robotic). Patient were similar in age, gender and co-morbidities. LIHR patients had higher BMI and RIHR patients had larger hernia and mesh size. LOS was longer and rate of SSI was higher for OIHR compared to laparoscopic and RIHR. Patients undergoing LIHR reported increased narcotic use, Visual Analogue Scale (VAS) and CCS pain scores compared to open and robotic repair. Return to daily activity was 4 days shorter for robotic than open and laparoscopic repair; ED visits, readmissions, reoperations, and other QOL domains were similar. CONCLUSION: Our data suggests that short-term quality of life after robotic extra-peritoneal IHR is improved compared to open and laparoscopic repair. Additional follow up is required to determine differences in long-term QOL after IHR.

A new method of robot-assisted laparoscopic repair of perineal hernia after abdominoperineal resection: a case report.

INTRODUCTION: Perineal hernia is a protrusion of the pelvic floor which contains intra-abdominal viscera. The occurrence of perineal hernia after abdominoperineal resection (APR) is rare, but it has been reported in recent years that the incidence of perineal hernia after rectal cancer surgery has increased. This has been attributed to a shift towards extralevator abdominoperineal resection, together with more frequent and long-term use of neoadjuvant therapy. PRESENTATION OF CASE: Here, we report a patient with perineal hernia 5 years after APR surgery for rectal cancer. We decided to perform robot-assisted laparoscopic surgery on this patient using the da Vinci Surgical System. The perineal hernia was repaired by primary closure with the placement of a non-absorbable synthetic mesh as reinforcement for the pelvic floor. No complications occurred during the operation, and the patient was discharged on the third day after the operation. Clinical follow-up proceeded at the designated time intervals without difficulties. DISCUSSION: The recurrence rates of perineal hernia are still very high, and due to poor view, suturing, and mesh placement in the deep pelvis, surgeons face many challenges. Many methods have been described, but there is still no consensus as to the optimal repair technique for perineal hernia. CONCLUSION: Perineal hernias can be repaired with robot-assisted laparoscopy. Furthermore, compared with the open and laparoscopic methods, suturing and mesh placement are easier with the robot approach.