Laparoscopic vs. ultrasound-guided transversus abdominis plane (TAP) block in colorectal surgery: a systematic review and meta-analysis of randomized trials.

BACKGROUND: The transversus abdominis plane block (TAPB) is effective for postoperative pain management in patients undergoing colorectal surgery. However, evidence regarding the optimal delivery method, either laparoscopic (L-TAPB) or ultrasound-guided (U-TAPB) is lacking. Our study aimed to compare the effectiveness of these delivery methods. METHODS: We carried out a literature search of PubMed, Cochrane Library, Web of Science, and Google Scholar databases to include randomized studies comparing patients receiving either L-TAPB or U-TAPB during minimally invasive colorectal surgery. The primary endpoint was opioid consumption in the first 24 h after surgery. Risk of bias was assessed with the RoB-2 tool. Effect size was estimated for each study with 95% confidence interval and overall effect measure was estimated with a random effect model. RESULTS: The literature search revealed 294 articles, of which four randomized trials were eligible. A total of 359 patients were included, 176 received a L-TAPB and 183 received a U-TAPB. We established the non-inferiority of L-TAPB, as the absolute difference of - 2.6 morphine-mg (95%CI - 8.3 to 3.0) was below the pooled non-inferiority threshold of 8.1 morphine-mg (low certainty level). No difference in opioid consumption was noted at 2, 6, 12, and 48 h (low to very low certainty level). Postoperative pain, nausea and vomiting were similar between groups at different timepoints (low to very low certainty level). No TAPB-related complications were recorded. Finally, the length of hospital stay was similar between groups. CONCLUSION: For postoperative multimodal analgesia both L-TAPB and U-TAPB may result in little to no difference in outcome in patients undergoing colorectal surgery. Registration Prospero CRD42023421141.

Trocar-site incisional hernia after 8-mm robotic trocar placement: A prospective study.

BACKGROUND: The current literature supports the closure of trocar sites ≥10-mm for the risk of developing incisional hernias, while there is no need to suture the abdominal fascia when using 5-mm trocars. To date, evidence regarding the closure of 8-mm trocars that are use by new robotic systems is weak. The aim of our study was to investigate the incidence of incisional hernia for 8-mm trocars. METHODS: We prospectively collected data on all patients undergoing robotic-assisted abdominal wall surgery from 2020 to 2023, in whom the abdominal fascia of all 8-mm trocars was not closed. The enrolled patients underwent a follow-up visit during which we conducted clinical and sonographic evaluations of all 8-mm trocars, in addition to assessing the satisfaction levels of the patients. The primary outcome was the incidence of port-site hernia. RESULTS: We enrolled 166 patients, 155 men and 11 women, for a total of 513 trocars accessed. Mean age was 61.1 ± 14.0 years, and mean BMI was 27.0 ± 3.9 kg/m2. The follow-up visits were carried out after a median follow-up of 14.5 (9.0-23.2) months. Only one case developed an asymptomatic 1 × 1 cm supra-umbilical hernia that was not treated. Patient reported a satisfaction regarding the 8-mm trocars and skin sutures of 9.8 ± 0.5 out of 10 points. CONCLUSIONS: The occurrence of a trocar-site hernia after 8-mm robotic access is extremely low. Hence, the fascia closure may not be necessary.

Safety and feasibility of emergency robot-assisted transabdominal preperitoneal repair for the treatment of incarcerated inguinal hernia: A retrospective study.

BACKGROUND: Few studies assessed robotic in emergency setting and no solid evidence was demonstrated. The aim of this study was to evaluate the feasibility and safety of robot-assisted transabdominal preperitoneal (R-TAPP) repair for the treatment of incarcerated inguinal hernia. METHODS: We retrospectively searched from a prospectively maintained database patients who underwent R-TAPP or open surgery for incarcerated inguinal hernias from January 2018 to March 2023. The primary endpoint was to assess safety and feasibility of the R-TAPP compared to the standard approach. For eligible patients, data was extracted and analyzed using a propensity score-matching (PSM). RESULTS: Thirty-four patients were retrieved from our database, 15 underwent R-TAPP, while 19 underwent open surgery. Mean age was 73.1 ± 14.6 years, 30 patients (88.2%) were male and mean BMI was 23.5 ± 3.2 kg/m2. No intraoperative complication occurred. Three cases requiring small bowel resection were all in the open surgery group (p = 0.112). The operative time was 108 ± 31 min versus 112 ± 31 min in the R-TAPP and open surgery groups (p = 0.716). Seven postoperative complications occurred, only one classified as severe was in the open surgery group. The length of hospital stay was 2.9 ± 1.8 in the R-TAPP versus 4.2 ± 2.3 min in the open surgery group (p = 0.077). PSM analysis showed similar postoperative outcomes and costs in both groups. CONCLUSIONS: Despite its limitations, our study appears to endorse the safety and feasibility of the robotic-assisted treatment for incarcerated inguinal hernia. This approach yielded comparable results to open surgery, albeit in a limited number of patients, suggesting it might be a viable alternative.

Laparoscopic versus ultrasound-guided transversus abdominis plane block in colorectal surgery: a non-inferiority, multicentric randomized double-blinded clinical trial.

AIM: The aim of this study was to assess if laparoscopic-assisted transversus abdominis plane (TAP) block (L-TAPB) is as efficient as ultrasound-guided TAP block (U-TAPB) in postoperative pain control. METHOD: In all, 112 patients scheduled for elective laparoscopic colon resection from February 2018 to December 2021 at two Swiss hospitals were included and randomized in a 1:1 ratio before surgery with either L-TAPB or U-TAPB. The primary end-point was the non-inferiority of the L-TAPB compared to U-TAPB with regard to the total opioid consumption within the first 24 h after surgery. Data regarding patients' characteristics, opioid consumption, pain on the visual analogue scale, operative and anaesthesia induction time, complications and length of stay were collected and analysed. RESULTS: Fifty-five patients were allocated to the L-TAPB and fifty-seven to the U-TAPB. No significant difference was found in the overall dose of opioids within 24 h, and the non-inferiority of the L-TAPB was confirmed. There were almost twice as many patients in the L-TAPB group requesting opioid reserves compared to the U-TAPB group (54.5% vs. 29.8%, P = 0.008). The anaesthesia induction time was significantly longer in the U-TAPB group (17 ± 11 min vs. 23 ± 12 min, P = 0.014). For all other variables (pain on the visual analogue scale, opioid consumption, need of epidural analgesia, operating time, postoperative complications and hospital stay) no statistically significant difference between the L-TAPB and the U-TAPB groups was noted. CONCLUSION: Our results showed the non-inferiority of the laparoscopic delivery compared to ultrasound-guided administration of the TAP block, with the advantage of not affecting anaesthesia times. STUDY REGISTRATION NUMBER: 2017-02017 CE 3294, ClinicalTrials.gov identifier NCT04575233.

Reoperative bariatric surgery after primary laparoscopic gastric plication for morbid obesity: a systematic review and meta-analysis.

BACKGROUND: Laparoscopic gastric plication (LGP) often requires reoperative bariatric surgery (RBS) due to complications and insufficient weight loss. The aim of our study was to assess perioperative morbidity and weight loss during follow-up in patients undergoing RBS after primary LGP for morbid obesity. METHODS: A search of PubMed, Web of Science, Cochrane Library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using ("conversion"OR "revision*""OR "reoperat*")AND("gastric"OR "curvatur*")AND "plication." Studies were deemed eligible if data on RBS after LGP were provided. For each study, data were extracted and analyzed. RESULTS: In the literature review, 291 articles were screened and 7 included. The studies covered a total of 367 patients, of whom 119 received a sleeve gastrectomy (SG), 85 a Roux-en-y gastric bypass (RYGB), 75 a one anastomosis-gastric bypass (OAGB), 45 a re-LGP, and 25 a jejuno-ileal bypass. After RBS, excess weight loss was 50.8 ± 6.5% at 6 months, 71.0 ± 7.7% at 12 months, and 89.0 ± 7.8% at 24 months. Operative time was 101.3 ± 14.6 min. Postoperatively, 18/255 patients (7.1%) had a complication, and leakage and reoperations were reported in 6/255 (2.4%) and 5/255 (2.0%) patients, respectively. Length of hospital stay was 3.1 ± 2.4 days. The quality of evidence was rated as "very low." CONCLUSIONS: Despite limitations, this systematic review and meta-analysis showed that RBS after LGP has an acceptable rate of complications and is effective in terms of excess weight loss during follow-up. No specific operation (e.g., SG, RYGB, OAGB) can be suggested over another due to the lack of evidence.

Three-point mesh fixation in robot-assisted transabdominal preperitoneal (R-TAPP) repair of 208 inguinal hernias: preliminary results of a single-center consecutive series.

PURPOSE: The aim of this study was to assess the efficacy of our mesh fixation technique in robot-assisted transabdominal preperitoneal inguinal hernia repair (R-TAPP). The primary outcome was the recurrence rate. Secondary outcomes were postoperative pain, chronic pain, and return to normal activities. METHODS: Between January 2018 and December 2019, we performed 208 consecutive R-TAPP in 161 patients and the mesh was fixed by three intracorporeal stiches using a Polyglactin 910 (Vicryl®) 3-0 suture. Patients were followed up at 10 and 30 days after surgery with a clinical evaluation for detection of early complications, postoperative pain, need for analgesics, return to normal activities, and satisfaction rate. Patients were further followed up at study conclusion in February 2021 for recurrence and chronic pain detection. RESULTS: Painkillers were stopped by 57% of the patients after the first postoperative day and by 96% after 1 week. Chronic pain (> 3 months after surgery) was observed in three patients (1.8%) and only one of them was treated with percutaneous ilioinguinal-iliohypogastric nerve infiltration. After a mean follow-up of 24.0 ± 6.7 months, only 1 recurrence (0.48%) was clinically detected and confirmed by a CT-scan. CONCLUSIONS: The 3-point mesh fixation technique is feasible during robot-assisted TAPP repair for inguinal hernia and seems to be a viable alternative to other fixation methods. Further long-term controlled investigations are needed to understand if this technique is effective in influencing recurrence and chronic pain rates.

Pudendal Nerve Block in Hemorrhoid Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Postoperative pain represents an important issue in traditional hemorrhoidectomy. Optimal pain control is mandatory, especially in a surgical day care setting. OBJECTIVE: The aim of this study was to investigate the use of pudendal nerve block in patients undergoing hemorrhoidectomy. DATA SOURCES: PubMed, Google Scholar, Cochrane Library, and Web of Science databases were searched up to December 2020. STUDY SELECTION: Randomized trials evaluating the pudendal nerve block effect in patients undergoing hemorrhoidectomy were selected. INTERVENTIONS: Hemorrhoidectomy under general or spinal anesthesia with or without pudendal nerve block was performed. MAIN OUTCOME MEASURES: Opioid consumption, pain on the visual analogue scale, length of hospital stay, and readmission rate were the main outcomes of interest and were plotted by using a random-effects model. RESULTS: The literature search revealed 749 articles, of which 14 were deemed eligible. A total of 1214 patients were included, of whom 565 received the pudendal nerve block. After hemorrhoidectomy, patients in the pudendal nerve block group received opioids less frequently (relative risk, 0.364; 95% CI, 0.292-0.454, p < 0.001) and in a lower cumulative dose (standardized mean difference, -0.935; 95% CI, -1.280 to -0.591, p < 0.001). Moreover, these patients experienced less pain at 24 hours (standardized mean difference, -1.862; 95% CI, -2.495 to -1.228, p < 0.001), had a shorter length of hospital stay (standardized mean difference, -0.742; 95% CI, -1.145 to -0.338, p < 0.001), and had a lower readmission rate (relative risk, 0.239; 95% CI, 0.062-0.916, p = 0.037). Sensitivity analysis excluded the occurrence of publication bias on the primary end point, and the overall evidence quality was judged "high." LIMITATIONS: Occurrence of publication bias among some secondary end points and heterogeneity are the main limitations of this study. CONCLUSIONS: This systematic review and meta-analysis show significant advantages of pudendal nerve block use. A reduction in opioid consumption, postoperative pain, complications, and length of stay can be demonstrated. Despite the limitations, pudendal nerve block in patients undergoing hemorrhoidectomy should be considered.

Learning curve of robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias.

BACKGROUND: Learning curves describe the rate of performance improvements according to the surgeon's caseload, followed by a plateau where limited additional improvements are observed. The aim of this study was to evaluate the learning curve for robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias in surgeons already experienced in laparoscopic TAPP. METHODS: The study was approved by local ethic committee. Male patients undergoing rTAPP for inguinal hernia from October 2017 to December 2019 at the Bellinzona Regional Hospital were selected from a prospective database. Demographic and clinical data, including operative time, conversion to laparoscopic or open surgery, intra- and postoperative complications were collected and analyzed. RESULTS: Over the study period, 170 rTAPP were performed by three surgeons in 132 patients, and mean age was 60.1 ± 13.7 years. The cumulative summation (CUSUM) test showed a significant operative time reduction after the 43rd operation, once the 90% proficiency on the logarithmic tendency line was achieved. The corrected operative time resulted 71.1 ± 22.0 vs. 60.8 ± 13.5 min during and after the learning curve (p = 0.011). Only one intraoperative complication occurred during the learning curve and required an orchiectomy. Postoperatively, three complications (one seroma, one hematoma, and one mesh infection) required invasive interventions during the learning curve, while no cases were recorded after it (p = 0.312). CONCLUSION: Our study shows that the rTAPP, performed by experienced laparoscopists, has a learning curve which requires 43 inguinal hernia repairs to achieve 90% proficiency and to significantly reduce the operative time.

Suture and Fixation of the Transversalis Fascia during Robotic-Assisted Transabdominal Preperitoneal Hernia Repair to Prevent Seroma Formation after Direct Inguinal Hernia Repair.

Background. Seroma formation after videoendoscopic repair of inguinal hernias, known as "pseudorecurrence", may vary from an asymptomatic, self-limiting occurrence to a painful, chronic problem. The aim of this study was to investigate the incidence of postoperative seroma in robotic-assisted transabdominal preperitoneal hernia repair (R-TAPP), modified by suturing and fixating the transversalis fascia to the Cooper ligament. Methods. The study was approved by the local ethics committee (2019-01132 CE-3495). Patients undergoing R-TAPP for direct inguinal hernia from October 2017 to December 2019 were included. In all patients, a barbed running suture of the transversalis fascia was performed to close the cavity resulting from the direct hernia reduction and to fix it to the Cooper ligament, then a lightweight mesh was placed. Demographic and clinical data were collected and analysed. Results. Over the study period, 67 R-TAPP in 51 patients were identified. All patients were male, with a mean age of 63.1 ± 12.7 years. There was 1 case of conversion to open surgery due to adhesions of the caecum to the groin as a result of perforated appendicitis. The mean length of the hospital stay was 1.8 ± .6 days. After discharge, no cases of seroma or recurrence at 30 days nor chronic pain at a mean follow-up of 10.3 ± 6.8 months was detected. Conclusions. In the treatment of direct inguinal hernia with R-TAPP, suturing and anchoring the transversalis fascia to the Cooper ligament are safe, feasible and recommendable in order to prevent postoperative seromas.

Clinical Adverse Events after Endoscopic Resection for Colorectal Lesions: A Meta-Analysis on the Antibiotic Prophylaxis.

BACKGROUND: Post-polypectomy coagulation syndrome (PECS) is a well-known adverse event after endoscopic polypectomy for colorectal lesions. To date, there are no standardized guidelines for the antimicrobial prophylaxis. The aim of this meta-analysis is to evaluate the usefulness of antibiotics in patients undergoing endoscopic mucosal or submucosal resections. METHODS: A comprehensive literature search of PubMed, MEDLINE, EMBASE, and Web of Science databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating the role of prophylactic antibiotic administration in reducing the PECS after endoscopic polypectomy were considered. The terms used to search were ("antimicrobial"OR"antibiotics"OR"prophylaxis"OR"prophylactic") AND ("resection"OR"polypectomy"OR"dissection") AND ("endoscopic"OR"mucosal"OR"submucosal") AND ("colon"OR"colorectal"OR"colonic"OR"rectum"). Data of included studies were collected and analysed. RESULTS: The literature search revealed 262 articles, 3 of whom were randomized trials and one was a retrospective study. Patients included were 850 (548 treated with antibiotics and 302 received no treatment). The overall incidence rate was 2.4 and 19.9% in treatment and control groups, respectively. The pooled analysis showed a reduction of 83% of postoperative events in the antibiotics group (relative risk 0.181; 95% CI 0.100-0.326, p < 0.001). CONCLUSIONS: In our meta-analysis, the antibiotic prophylaxis showed a positive effect in reducing the incidence of postoperative adverse events other than perforation and bleeding in patients treated with endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions. Despite the low-level of evidence of this meta-analysis, the antibiotic prophylaxis should be taken into account. Further multicenter, large-sample, randomized controlled studies are needed to confirm our results and to evaluate whether specific subgroups of patients could actually benefit from an antibiotic prophylaxis.

Ultrasound-guided pudendal nerve block in patients undergoing open hemorrhoidectomy: a double-blind randomized controlled trial.

PURPOSE: In this double-blind randomized trial, we aimed to compare the postoperative pain, complications, and length of hospital stay in patients undergoing open hemorrhoidectomy under spinal anesthesia with or without the pudendal nerve block. METHODS: Patients undergoing Milligan-Morgan hemorrhoidectomy under spinal anesthesia were randomized to undergo a pudendal nerve block or no intervention. Postoperative pain on the visual analogue scale (VAS) at 6, 12, 24, and 48 h; opioid administration; and length of hospital stay were recorded and analyzed. RESULTS: Over the study period, 49 patients were included and 23 randomized in the treatment arm. No differences in terms of age, gender, and preoperative risk factors were noted between groups. The pain on the VAS at 6, 12, 24, and 48 h was 2.8 vs. 4.6 (p = 0.046), 3.4 vs. 4.7 (p = 0.697), 1.4 vs. 3.1 (p = 0.016), and 1.0 vs. 2.1 (p = 0.288) in the treatment and control groups respectively. No differences in opioids use or complications were noted. Length of hospital stay was 1.2 vs. 1.8 days respectively (p = 0.046). No complications directly associated to the pudendal nerve block were observed. Multivariate analysis revealed that the pudendal nerve block was an independent factor reducing the postoperative pain. CONCLUSIONS: The ultrasound-guided pudendal nerve block in patients undergoing open hemorrhoidectomy under spinal anesthesia showed a statistically significant reduction in postoperative pain and length of hospital stay. The proposed technique appeared to be safe and feasible and may be recommendable in patients undergoing open hemorrhoidectomy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04251884.

Robotic assisted treatment of flank hernias: case series.

BACKGROUND: Flank hernias are uncommon, surgical treatment is challenging and the minimally-invasive approach not always feasible. The aim of this study was to report the safety and feasibility of the robotic-assisted repair. METHODS: The study was approved by the local ethic committee (2019-01132 CE3495). A retrospective search on a prospectively collected dataset including demographic and clinical records on robotic surgery at our institution was performed to identify patients treated for a flank hernia. Patients were followed-up 6 months. RESULTS: From January 2018 to December 2019, out of 190 patients who underwent robotic-assisted hernia surgery, seven with incisional flank hernia were included. Median age was 69.0 years (IQR 63.2-78.0), BMI was 27.3 kg/m2 (IQR 25.8-32.3) and two patients were male (29%). All patients were referred to surgery because of pain, whereas one of them described recurrent episodes of small bowel obstruction. The median hernia defect measured 25 mm ((IQR 21-40), median mesh diameter was 10 cm (IQR 10-12.5) and median operative time was 137 min (IQR 133-174). No intraoperative complication occurred. Postoperatively, one patient developed a pneumonia, which required antibiotics. Length of hospital stay was 4.0 days (IQR 3.0-7.7). Six months after surgery, neither recurrence nor chronic pain were recorded. CONCLUSIONS: Robotics in abdominal wall hernia surgery remains a matter of debate, despite a growing interest from the surgical community. In our reported experience with flank hernias, we found the robotic-assisted approach to be safe and feasible for the treatment of this uncommon clinical entity.

Gallbladder Retrieval From Epigastric Versus Umbilical Port in Laparoscopic Cholecystectomy: A PRISMA-Compliant Meta-Analysis.

Purpose. To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons' preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: ("gallbladder" OR "cholecystectomy") AND "umbilical" AND ("epigastric" OR "subxiphoid"). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results. Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site (P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions. This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

Antibiotic administration after cholecystectomy for acute mild-moderate cholecystitis: a PRISMA-compliant meta-analysis.

INTRODUCTION: Acute cholecystitis is a common disease and a frequent cause of emergency admission to surgical wards. Evidence regarding antibiotic administration in urgent procedures is limited and remains a contentious issue. According to the Tokyo guidelines, the antibiotic administration should be guided by the severity of cholecystitis, but internationally accepted guidelines are lacking. In particular, the need to perform antibiotic therapy after laparoscopic cholecystectomy is controversial for mild and moderate acute calculous cholecystitis (Tokio I and II). MATERIALS AND METHODS: We performed a comprehensive computer literature search of PubMed and MEDLINE databases in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. We selected patients treated with cholecystectomy for mild or moderate acute calculous cholecystitis (Tokio I or II), only randomized controlled trials, (post-operative antibiotic administration versus placebo or untreated), data about local or systemic infection rate in the next 30 days after surgery. RESULTS: Three hundred and fifty-nine articles were identified, and three articles were considered eligible for the meta-analysis, including 676 patients. Overall surgical site infections were documented in 18 (5.49%) of 328 patients treated with post-operative antibiotics versus 25 (7.18%) of 348 patients treated without post-operative antibiotics. Overall results and the subgroup analysis (superficial and deep incisional infection and organ/space infection) showed no statistically significant reduction of surgical site infections rate under antibiotic therapy. CONCLUSIONS: Our meta-analysis shows no significant benefit of extended antibiotic therapy in reducing SSI after cholecystectomy for mild and moderate acute cholecystitis (Tokio I and II). Further RCTs with adequate statistical power and involving a higher number of patients with subgroups are needed to better evaluate the benefit of post-operative antibiotic treatment in reducing the rate of organ/space surgical site infections.

Safety, feasibility and clinical outcome of minimally invasive inguinal hernia repair in patients with previous radical prostatectomy: A systematic review of the literature.

BACKGROUND: Radical prostatectomy (RP) represents an important acquired risk factor for the development of primary inguinal hernias (IH) with an estimated incidence rates of 15.9% within the first 2 years after surgery. The prostatectomy-related preperitoneal fibrotic reaction can make the laparoendoscopic repair of the IH technically difficult, even if safety and feasibility have not been extensively evaluated yet. We conducted a systematic review of the available literature. METHODS: A comprehensive computer literature search of PubMed and MEDLINE databases was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Terms used to search were ('laparoscopic' OR 'laparoscopy') AND ('inguinal' OR 'groin' OR 'hernia') AND 'prostatectomy'. RESULTS: The literature search from PubMed and MEDLINE databases revealed 156 articles. Five articles were considered eligible for the analysis, including 229 patients who underwent 277 hernia repairs. The pooled analysis indicates no statistically significant difference of post-operative complications (Risk Ratios [RR] 2.06; 95% confidence interval [CI] 0.85-4.97), conversion to open surgery (RR 3.91; 95% CI 0.85-18.04) and recurrence of hernia (RR 1.39; 95% CI 0.39-4.93) between the post-prostatectomy group and the control group. There was a statistically significant difference of minor intraoperative complications (RR 4.42; CI 1.05-18.64), due to an injury of the inferior epigastric vessels. CONCLUSIONS: Our systematic review suggests that, in experienced hands, safety, feasibility and clinical outcomes of minimally invasive repair of IH in patients previously treated with prostatectomy, are comparable to those patients without previous RP.

Use of retrieval bag in the prevention of wound infection in elective laparoscopic cholecystectomy: is it evidence-based? A meta-analysis.

BACKGROUND: Surgical site infections complicate elective laparoscopic cholecystectomies in 2,4-3,2% of cases. During the operation the gallbladder is commonly extracted with a retrieval bag. We conducted a meta-analysis to clarify whether its use plays a role in preventing infections. METHODS: Inclusion criteria: elective cholecystectomy, details about the gallbladder extraction and data about local or systemic infection rate. EXCLUSION CRITERIA: cholecystitis, jaundice, concurrent antibiotic therapy, immunosuppression, cancer. A comprehensive literature search of PubMed, Cochrane Library and MEDLINE databases was carried out independently by two researchers, according to the PRISMA guidelines and applying the GRADE approach. Terms used were ("gallbladder"AND("speciment"OR"extraction"OR"extract"))OR("gallbladder"OR"cholecystectomy")AND("bag"OR"retrieval|"OR|"endobag"OR"endocatch"). RESULTS: The comprehensive literature revealed 279 articles. The eligible studies were 2 randomized trials and a multicentre prospective study. Wound infections were documented in 14 on 334 (4,2%) patients operated using a retrieval bag versus 16 on 271 (5,9%) patients operated without the use of a retrieval bag. The statistical analysis revealed a risk ratio (RR) of 0.82 (0.41-1.63 95% CI). Concerning sensitivity analysis the estimated pooled RR ranged from 0.72 to 0.96, both not statistically significant. Harbord test did not reveal the occurrence of small-study effect (p = 0.892) and the funnel-plot showed no noteworthy pattern. CONCLUSIONS: The results of this review highlight the paucity of well-designed large studies and despite limitations related to the low level of evidence, our meta-analysis showed no significant benefit of retrieval bags in reducing the infection rate after elective laparoscopic cholecystectomy. In absence of acute cholecystitis, accidental intraoperative gallbladder perforation or suspected carcinoma their use, to date, may not be mandatory, so that, further studies focusing on complex cases are needed.

Erector Spinae Plane Block versus Transversus Abdominis Plane Block for Robotic Inguinal Hernia Repair: A Blinded, Active-Controlled, Randomized Trial.

BACKGROUND: Regional anesthetic nerve blocks are widely used in the treatment of pain after outpatient surgery to reduce opioid consumption. Erector spinae plane (ESP) block is a recently described technique with promising results in different scenarios. OBJECTIVES: To compare ESP block efficacy with the commonly used transversus abdominis plane (TAP) block in patients undergoing robot-assisted inguinal hernia repair. STUDY DESIGN: This was a randomized, blinded, active controlled, superiority trial with 2 parallel groups. The study was approved by the local ethics committee. Registration took place on; www. CLINICALTRIALS: gov with the identifier NCT04750512. SETTING: Adults undergoing robotic inguinal hernia repair were recruited between January 2021 and April 2022 in a single referral center of southern Switzerland. METHODS: To ensure blinding, the study employed a "double dummy" design, where all patients underwent both TAP and ESP blocks, but only one block was therapeutically active. The therapeutic block contained ropivacaine 0.2%, while the other infiltration contained placebo. The therapeutic intervention varied between groups, with one group receiving the TAP block as the active treatment and the other group receiving the ESP block as the active treatment. Computer generated 1:1 randomization determined allocation, which took place immediately prior to the intervention. As a result, blinding included patients, anesthesia, and surgery providers, outcome assessors and statistical analysts. The main outcome measure was the highest reported pain score on a Visual Analog Scale (VAS) during the 6 hours following the end of general anesthesia. Secondary outcomes included pain scores at set intervals, analgesic consumption, and complications. RESULTS: A total of 50 patients (25 per arm) were enrolled and included in the analysis. The study found no significant difference in the mean maximal VAS scores between the 2 groups (TAP block 22.2, ESP block 20, difference 2.2, 95% CI is -12.1 to 16.5). Secondary endpoints, including VAS pain scores at different time points, use of rescue analgesics, time to first walk, duration of stay, and frequency of adverse events, did not show any significant differences between the 2 groups. However, post-hoc analysis suggested a more stable effect over time for the ESP block compared to the TAP block. LIMITATIONS: The main limitation is a higher variance in VAS scores than expected in the power calculations. CONCLUSIONS: ESP block was not superior to TAP block in the treatment of post-operative pain among patients undergoing robotic inguinal hernia repair.

Switching from robotic-assisted extended transabdominal preperitoneal (eTAPP) to totally extraperitoneal (eTEP) hernia repair for umbilical and epigastric hernias.

Our study aimed to assess the safety and effectiveness of the robotic-assisted extended totally extraperitoneal (eTEP) repair compared to transabdominal preperitoneal (eTAPP) repair with a suprapubic trocar insertion to treat umbilical and epigastric hernias. On a prospectively maintained database, we identified patients who underwent either eTEP or eTAPP for treating umbilical and epigastric hernias. During the study period, 53 patients were included, 32 in the eTEP group and 21 in the eTAPP group. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male, and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). The operative time for eTEP was slightly shorter than for eTAPP (106 ± 43 min vs. 126 ± 74 min, p = 0.232). Postoperatively, only one case of bleeding and one seroma were recorded. No complication occurred during a mean follow-up of 11.3 ± 6.4 months in the eTEP group and 20.5 ± 9.7 months in the eTAPP group. In conclusion, our study showed that the eTEP with suprapubic approach was safe and feasible in the treatment of epigastric and umbilical hernias. According to our experience, shorter operative time, integrity of the posterior layers and increased overlap size are the main surgical reasons of switching from eTAPP to eTEP.

Hospital costs of robotic-assisted and open treatment of large ventral hernias.

Robotic-assisted treatment of ventral hernia offers many advantages, however, studies reported higher costs for robotic surgery compared to other surgical techniques. We aimed at comparing hospital costs in patients undergoing large ventral hernia repair with either robotic or open surgery. We searched from a prospectively maintained database patients who underwent robotic or open surgery for the treatment of the large ventral hernias from January 2016 to December 2022. The primary endpoint was to assess costs in both groups. For eligible patients, data was extracted and analyzed using a propensity score-matching. Sixty-seven patients were retrieved from our database. Thirty-four underwent robotic-assisted surgery and 33 open surgery. Mean age was 66.4 ± 4.1 years, 50% of patients were male. After a propensity score-matching, a similar total cost of EUR 18,297 ± 8,435 vs. 18,024 ± 7514 (p = 0.913) in robotic-assisted and open surgery groups was noted. Direct and indirect costs were similar in both groups. Robotic surgery showed higher operatory theatre-related costs (EUR 7532 ± 2,091 vs. 3351 ± 1872, p < 0.001), which were compensated by shorter hospital stay-related costs (EUR 4265 ± 4366 vs. 7373 ± 4698, p = 0.032). In the treatment of large ventral hernia, robotic surgery had higher operatory theatre-related costs, however, they were fully compensated by shorter hospital stays and resulting in similar total costs.