Standardized porcine integrated robotic inguinal hernia training: the SPIRIT model.

BACKGROUND: Implementing a robotic system for minimally invasive surgical procedures necessitates a comprehensive training regimen. This involves not only mastering the technological aspects of the robotic system but also enhancing surgical proficiency in manipulating robotic instruments. Furthermore, procedural expertise in specific surgeries is critical. Minimally invasive inguinal hernia repair is particularly suitable as an initial procedure for human application. The development of a comprehensive training model for this type of repair is a crucial element of such an educational pathway. METHOD: Anatomical dissections were carried out on pigs to assess both the similarities and differences between pig and human anatomy. A structured minimally invasive inguinal hernia repair was performed to determine the suitability of the porcine inguinal region for training purposes. RESULTS: A detailed anatomical description of the porcine inguinal region is outlined, to provide a framework for assessing the critical view of the porcine myopectineal orifice. By integrating the human 'ten golden rules' for safe and effective minimally invasive inguinal hernia repair, the standardized porcine integrated robotic inguinal hernia training (SPIRIT) model describes a step-by-step approach to practice surgical techniques in a realistic setting. CONCLUSION: The SPIRIT model is designed to be a well-structured training model for minimally invasive inguinal hernia repair and incorporates the specific surgical steps as encountered in a human patient.

Prospective cohort study on mesh shrinkage measured with MRI after robot-assisted minimal invasive retrorectus ventral hernia repair using an iron-oxide-loaded polyvinylidene fluoride mesh.

BACKGROUND: Mesh-reinforced ventral hernia repair is considered the gold standard treatment for all but the smallest of hernias. Human data on mesh shrinkage in the retrorectus mesh position is lacking. A prospective observational cohort study was performed to measure mesh shrinkage in robot-assisted minimal invasive retrorectus repair of ventral hernias. METHODS: A cohort of 20 patients underwent a robot-assisted minimal invasive retrorectus repair of their ventral hernia. Magnetic resonance imaging (MRI) imaging was performed one month and thirteen months after implantation of an iron-oxide-impregnated polyvinylidene fluoride (PVDF) mesh to assess the decrease in mesh surface area. Inter-rater reliability among three radiologists regarding measurement of the mesh dimensions was analyzed. Quality of Life scoring was evaluated. RESULTS: The inter-rater reliability between the radiologists reported as the intra-class correlations proved to be excellent for mesh width (ICC 0.95), length (ICC 0.98) and surface area (ICC 0.99). Between MRI measurements at one month and thirteen months postoperatively, there was a significant increase in mesh surface area (+ 12.0 cm2, p = 0.0013) and mesh width (+ 0.8 cm, p < 0.001), while the length of the mesh remained unchanged (-0.1 cm, p = 0.754). Quality of Life Scoring showed a significant improvement in Quality of Life after one month and a further improvement at thirteen months (p < 0.001). CONCLUSION: There was an excellent inter-rater reliability between three radiologists when measuring width, length, and surface area of an iron-oxide-impregnated PVDF mesh using MRI visualization. Mesh shrinkage was not observed, instead the effective mesh surface area and width of the mesh increased.

Aortic thrombosis and acute limb ischemia after ChAdOx1 nCov-19 (Oxford-AstraZeneca) vaccination: a case of vaccine-induced thrombocytopenia and thrombosis (VITT).

INTRODUCTION: Vaccine-induced thrombocytopenia and thrombosis (VITT) is a rare but devastating adverse event associated with the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) adenoviral vaccine against the Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2). METHODS: A 49-year-old man presented to the emergency department with acute right limb ischemia (Rutherford IIB) nine days after his ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccination. CT angiography revealed significant aortic thrombosis and right femoral artery occlusion. Severe thrombocytopenia (platelet count of 23 × 103/µL), promptly elevated D-dimers (37937 ng/mL) and a reduced fibrinogen level (176 mg/dL) were remarkable. ELISA testing for anti-PF4 antibodies confirmed the diagnosis of VITT. RESULTS: An emergency revascularization of the right leg was provided via thrombectomy. High-dose intravenous immunoglobulins were administered whereafter the platelet count restored gradually. Therapeutic anticoagulation was progressively started. The postoperative course was uneventful and follow-up imaging after four weeks showed an almost complete resolution of the significant aortic thrombosis. CONCLUSION: Early recognition and appropriate counseling of VITT is advocated to pursue a good clinical outcome. Our patient presenting with severe aortic thrombosis and acute limb ischemia was successfully treated by a vascular thrombectomy along with intravenous immunoglobulins and anticoagulation therapy as the mainstay therapy.

Symptomatic gastric involvement in a parastomal hernia: uncommon presentation.

Introduction: A parastomal hernia (PSH) is the most common complication of a stoma creation. The PSH contents normally consist of mobile abdominal structures, i.e. omentum and small or large bowel loops. A herniated stomach is thereby very rare, given that only eight cases are reported in the literature.Patients and methods: Two female patients with clinical symptoms of gastric involvement in a PSH were admitted in our centre.Results: Computed tomography (CT) imaging, nasogastric decompression and an efficient operative intervention ensured a good clinical outcome in both patients, but with a long hospital stay and temporary gastroparesis in one patient. Regarding our two cases and the eight cases reported in the literature, mainly older females with colostomies are at risk and most of them need surgery. Conclusions: In patients presenting with obstructive symptoms, one should be aware of a possible gastric outlet obstruction because of its involvement in a PSH, although sporadic. Surgery might be considered as the treatment of choice because conservative treatment mostly fails. Earlier surgery might perhaps also reduce postoperative hospital stay and gastroparesis.

Effect of treatment sequence on survival in stage IV rectal cancer with synchronous and potentially resectable liver metastases.

BACKGROUND AND OBJECTIVES: The optimal treatment sequence in stage IV rectal cancer (RC) with synchronous liver metastases (SLM) remains undefined. Here, we compared outcomes between patients treated with the bowel-first approach (BFA) or the liver-first approach (LFA). METHODS: Consecutive patients diagnosed with stage IV RC with SLM and who underwent complete resection were included. Both groups were matched using propensity scores. Differences in postoperative outcome, local control, and long-term survival were studied. In addition, a decision analysis (DA) model was built using TreeAge Pro to define the approach that results in the highest treatment completion rate. RESULTS: During a 12-year period, 52 patients were identified, 21 and 31 of whom underwent the BFA and the LFA, respectively. Twenty-eight patients were matched; patients treated with the BFA experienced a longer median OS (50.0 vs 33.0 months; P = .40) and higher 5-year OS (42.9% vs 28.6%). The DA defined the BFA to be superior when the failure threshold (ie, no R0 resection, treatment discontinuation regardless of cause) for colectomy is less than 28.6%. CONCLUSIONS: In stage IV rectal cancer with SLM, either the BFA or the LFA result in similar long-term outcomes. Treatment should be tailored according to clinicopathological variables.

Laparoscopic Versus Open Approach for Formal Right and Left Hepatectomy: A Propensity Score Matching Analysis.

BACKGROUND: Laparoscopic liver surgery is expanding worldwide, but further evidence is needed to assess safety and efficacy of laparoscopic major hepatectomy. The study analyzes perioperative outcomes of pure laparoscopic versus open major hepatectomies matched by the propensity score method. METHODS: From 2005 to 2017, 268 major hepatectomies were performed of which 73 were laparoscopic. After a 1:1 propensity score matching, 59 laparoscopic right and left hepatectomies were compared to 59 open. The matching was based on age, gender, year of procedure, BMI, ASA score, underlying liver disease, previous abdominal surgery, type of hepatectomy, preoperative chemotherapy, number, dimension and nature of lesions. An intention-to-treat analysis and a per-protocol analysis were carried out. RESULTS: Mean surgical time was 315 min in the laparoscopic group and 292.5 min in the open group (p = 0.039); conversion rate in laparoscopy was 20.3%; blood loss was 480 ml (50-3000) versus 550 ml (50-2600), respectively, for laparoscopic and open (p = 0.577). Lengths of postoperative analgesia and hospital stay were shorter in the laparoscopic group (p = 0.0001 and 0.024, respectively). Postoperative complications occurred in 11.9% of laparoscopic cases and in 25.4% of open cases (p = 0.098). Median Comprehensive Complication Index was 26.2 (8.7-54.2) in the open group versus 20.9 (8.7-66.2) in open (p = 0.368). Per-protocol analysis showed a better trend in favor of laparoscopy concerning surgical time. CONCLUSIONS: Laparoscopic major hepatectomies are safe and feasible procedures allowing a similar complication rate with a shorter hospital stay and diminished postoperative pain with respect to the standard approach.

Descriptive Anatomy of the Porcine Ventral Abdominal Wall as a Basis for Training Ventral Hernia Repair Techniques.

Background: In recent times there has been a surge in innovative techniques concerning complex abdominal wall surgery. The availability of simulation models for comprehensive training and skill set development remains limited. Methods: Cadaveric dissections of the porcine abdominal wall were conducted to assess the suitability of anesthetized porcine models for training in both minimally invasive and open surgical procedures. Results: The panniculus carnosus, a typical muscular layer in mammals, is the outermost layer covering the anterolateral abdominal wall. Beneath it, there are four main pairs of abdominal wall muscles, mirroring the human anatomy. The rectus abdominis muscle runs straight along the linea alba and is surrounded by the rectus sheath, which is formed by the fusion of the lateral abdominal wall muscles and differs along the different regions of abdominal wall. The orientation of the muscle fibers in the lateral abdominal wall muscles, i.e., musculus obliquus externus, internus and transversus, is comparable to human anatomy. Although the transition lines between their muscular and aponeurotic part differ to some extent. Relevant for the adoption of surgical techniques, the transversus abdominis muscle is well-developed and resembles a bell curve shape as it transitions from its muscular to aponeurotic part. Conclusion: Despite minor differences in abdominal wall anatomy between pigs and humans, the porcine model provides a high level of fidelity in terms of both anatomical features and the development of skill sets relevant to hernia surgery.

Are abbreviations and acronyms to describe hernia repair techniques overused and helpful? A proposal for rationalisation.

Surgeons use abbreviations and acronyms frequently to describe surgical techniques. Recent advances and innovations in repair of abdominal wall hernias, have given rise to a plenitude of novel acronyms. For each small deviation of an existing technique authors have proposed a novel acronym. Since an acronym is most of times not self-explaining it is often hard to understand literature, lectures, symposia programs and discussions in social media. Regularly, we discover different acronyms used for the same procedure and sometimes the same or similar acronyms are used for different techniques. A clear and non-ambivalent description of surgical techniques in the literature is most valuable to summarize scientific evidence in systematic reviews and meta-analyses. We would like to propose a more rational use of abbreviations to describe hernia repair techniques based on the type of access, type of hernia, mesh position, type of mesh used and type of mesh fixation.

History of the Creation of Self-Gripping Mesh.

Self-gripping mesh (ProgripTM, Sofradim Production, Trévoux, France) was introduced in 2006 as a synthetic prosthetic material for reinforcement of the abdominal wall in open inguinal hernia repair. As of September 2022, the self-gripping mesh has been implanted 4 million times. In June 2014 at the annual Mesh congress in Paris during an informal conversation with Dr. Chastan, Dr. Muysoms became intrigued by the history of the invention and creation of this self-gripping mesh. His fascination on this topic, was the initial bead implanted for this project to write down the history of the creation of self-gripping mesh.

EIT Ambivium, Linea Semilunaris, and Fulcrum Abdominalis.

Building upon the recent advancements in posterior component separation techniques for complex abdominal wall hernia repair, highlights the critical importance of a thorough understanding of the abdominal wall anatomy. To address anatomical concepts with a pivotal role in hernia repair, we propose two new terminologies: "EIT Ambivium" referring to the lateral border of the rectus sheath, and "Fulcrum Abdominalis" demarcating the point where the Linea Arcuata intersects with the EIT Ambivium.

A Left Paraduodenal Hernia: an "Incidental Finding" in a Virgin Abdomen with Small Bowel Obstruction.

BACKGROUND: A left paraduodenal hernia is a rare clinical condition, resulting from embryological abnormalities or anomalies of the peritoneal attachments. Preoperative diagnosis is difficult because of its nonspecific clinical manifestations. PRESENTATION OF A CASE: A 42-year-old man, with negative surgical history, presented to the emergency department with complaints of severe acute epigastric pain and vomiting of 12 h duration. The patient did not report any episodes of abdominal pain in his history. Computed tomography imaging was suggestive for a closed-loop obstruction. An emergency laparoscopy was performed, revealing a pathologically dilated tangle of jejunal loops and an incidental finding of a left paraduodenal hernia, the latter containing small bowel loops with normal caliber. The small bowel loops were reduced, and the hernia orifice was closed via non-absorbable sutures to restore normal anatomy. The pathologically dilated small bowel segment with serosal scar tissue, probably developed secondary to a previous episode of incarceration, was resected. RESULTS: A high level of clinical suspicion for a left paraduodenal hernia is advocated in patients with a virgin abdomen, presenting with recurrent vague abdominal pain or acute symptoms of small bowel obstruction. Usually, a left paraduodenal hernia is an incidental finding on computed tomography imaging or during diagnostic laparoscopy. Surgical repair is the mainstay therapy, even in asymptomatic cases, to prevent future small bowel incarceration which develops in almost half of the cases. The laparoscopic approach is feasible and safe, also in an emergency setting. CONCLUSIONS: By presenting this case, we assume to raise awareness as many clinicians are unfamiliar with this rare condition. Clinical suspicion and detailed knowledge of the etiology, anatomy, and vascular landmarks allow surgeons to accurately manage a left paraduodenal hernia.

Open versus robotic-assisted laparoscopic posterior component separation in complex abdominal wall repair.

BACKGROUND: Transversus abdominis release (TAR) is a surgical technique used in the treatment of complex ventral hernias. The aim of this study was to compare outcomes of open (oTAR) versus robotic-assisted (rTAR) posterior component separation by TAR. METHODS: Consecutive patients at two European hernia centres who underwent bilateral TAR were included. The primary endpoint was the duration of postoperative hospital stay. RESULTS: Data from 90 rTAR and 79 oTAR operations were evaluated. Patient demographics were similar between groups in terms of age, sex, BMI, and co-morbidities. There were more smokers, and hernias were larger in the oTAR group (width 8.7 cm versus 10.0 cm; P = 0.031, length 11.6 cm versus 14.1 cm; P = 0.005). Duration of postoperative hospital stay was significantly shorter in the rTAR group (3.4 days versus 6.9 days; P < 0.001). Short-term serious complications (Clavien-Dindo grade III and above) were more frequent (20.3 per cent versus 7.8 per cent; P = 0.018), and there were more surgical site infections (12.7 per cent versus 3.3 per cent; P = 0.010) in the oTAR group. During a median follow-up of 19 months in the rTAR group and 43 months in the oTAR group, reoperation (4.4 per cent versus 8.9 per cent; P = 0.245), and recurrence rates (5.6 per cent versus 5.1 per cent; P > 0.009) were similar. CONCLUSION: Patients with ventral incisional hernias who undergo bilateral rTAR had significantly shorter postoperative hospital stays and fewer short-term complications compared with patients undergoing bilateral oTAR.

Description of the Current Da Vinci® Training Pathway for Robotic Abdominal Wall Surgery by the European Hernia Society.

Background: Robot assisted laparoscopic abdominal wall surgery (RAWS) has seen a rapid adoption in recent years. The safe introduction of the robot platform in the treatment of abdominal wall hernias is important to safeguard the patient from harm during the learning curve. The scope of this paper is to describe the current European training curriculum in RAWS. Methods and Analysis: The pathway to competence in RAWS will depend on the robot platform, experience in other abdominal procedures (novice to expert) and experience in the abdominal wall repair techniques. An overview of the learning curve effect in the initial case series of several early adopters in RAWS was reviewed. In European centres, current training for surgeons wanting to adopt RAWS is managed by the specific technology-based training organized by the company providing the robot. It consists of four phases where phases I and II are preclinical, while phases III and IV focus on the introduction of the robotic platform into surgical practice. Conclusion: On behalf of the Robotic Surgery Task Force of the European Hernia Society (EHS) we believe that the EHS should play an important role in the clinical phases III and IV training. Courses organized in collaboration with the robot provider on relevant surgical anatomy of the abdominal wall and procedural steps in complex abdominal wall reconstruction like transversus abdominis release are essential. Whereas the robot provider should be responsible for the preclinical phases I and II to gain familiarity in the specific robot platform.

Surgical education interventions in liver surgery: a systematic review.

The objective of the study was to identify and to evaluate the impact of educational interventions to learn and train liver surgery outside the operating room. A systematic literature search was conducted using PubMed, Web of Science, Embase, and ERIC databases from inception to September 2019 according to the PRISMA guidelines. Studies describing and assessing outcomes of educational interventions in liver surgery, outside the operating room, were included. Neither language nor date of publication restriction was applied. Methodological quality was appraised using NOS-E (Newcastle-Ottawa Scale for Education), and the level of evidence was evaluated based on GRADE (Grades of Recommendation Assessment, Development, and Evaluation) standards. Of the 10,403 screened abstracts, 53 articles were eligible for inclusion, comprising 27 descriptive studies (50.9%), 14 case series assessing any relevant outcome (26.4%), 8 non-randomized controlled trials (15.1%), and 4 randomized controlled studies (7.5%). Almost half (26/53) of the studies did not include any participants, while the remainder of the publications (27/53) involved 1306 learners. The majority of the studies focused on cognitive knowledge (31/53) and/or psychomotor skills training (24/53). Only one publication assessed affective skills. The GRADE score was very low or low in most articles (46/53). Five studies were scored high (5-6) according to NOS-E. Two studies reported data regarding the reliability and validity of employed assessment tools. High-quality studies, particularly well-designed randomized controlled trials that evaluate the effectiveness of simulation-based training on learner behavior and patient outcomes in liver surgery, are still lacking. Forthcoming studies should use robust assessment tools supported by validity evidence.