Effective and safe implementation of robot-assisted donor nephrectomy by experienced laparoscopic surgeons.

BACKGROUND: In June 2021, the first robot-assisted donor nephrectomy (RADN) was performed at the Leiden University Medical Center (LUMC), the Netherlands. The goal of this study was to investigate whether this procedure has been implemented safely and efficiently. METHODS: RADN was retrospectively compared to laparoscopic donor nephrectomy (LDN) performed during the same time period (June 2021 until November 2022). Patients were assigned to RADN depending on the availability of the da Vinci robot and surgical team. The studied endpoints were postoperative complications, operative time, estimated blood loss, warm ischemic time (WIT), and postoperative pain experience. For analysis, the Student's t-test and Chi-squared test were used for, respectively, continuous and categorical data. RESULTS: Forty RADN were compared to 63 LDN. Total insufflation time was significantly longer in RADN compared to LDN (188 min (169-214) versus 172 min (144-194); p = 0.02). Additionally, WIT was also found to be significantly higher in the robot-assisted group (04:54 min vs. 04:07 min; p < 0.01). No statistical differences were found in postoperative outcomes (eGFR of the recipient at 3-month follow-up, RADN 54.08 mL/min ±18.79 vs. LDN 56.41 mL/min ±16.82; p = 0.52), pain experience, and complication rate. CONCLUSION: RADN was safely and efficiently implemented at the LUMC. It's results were not inferior to laparoscopic donor nephrectomy. Operative time and warm ischemic times were longer in RADN. This may relate to a learning curve effect. No clinically relevant effect on postoperative outcomes was observed.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial.

BACKGROUND: Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias. METHODS: We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230. FINDINGS: Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths. INTERPRETATION: This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size. FUNDING: Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence.

BACKGROUND: Incisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence. METHODS/DESIGN: The PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up. DISCCUSION: The use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups. TRIAL REGISTRATION: Clinical trial.gov NCT00761475.

Abdominal wound dehiscence in adults: development and validation of a risk model.

BACKGROUND: Several studies have been performed to identify risk factors for abdominal wound dehiscence. No risk model had yet been developed for the general surgical population. The objective of the present study was to identify independent risk factors for abdominal wound dehiscence and to develop a risk model to recognize high-risk patients. Identification of high-risk patients offers opportunities for intervention strategies. METHODS: Medical registers from January 1985 to December 2005 were searched. Patients who had primarily undergone appendectomies or nonsurgical (e.g., urological) operations were excluded. Each patient with abdominal wound dehiscence was matched with three controls by systematic random sampling. Putative relevant patient-related, operation-related, and postoperative variables were evaluated in univariate analysis and subsequently entered in multivariate stepwise logistic regression models to delineate major independent predictors of abdominal wound dehiscence. A risk model was developed, which was validated in a population of patients who had undergone operation between January and December 2006. RESULTS: A total of 363 cases and 1,089 controls were analyzed. Major independent risk factors were age, gender, chronic pulmonary disease, ascites, jaundice, anemia, emergency surgery, type of surgery, postoperative coughing, and wound infection. In the validation population, risk scores were significantly higher (P < 0.001) for patients with abdominal wound dehiscence (n = 19) compared to those without (n = 677). Resulting scores ranged from 0 to 8.5, and the risk for abdominal wound dehiscence over this range increased exponentially from 0.02% to 70.1%. CONCLUSIONS: The validated risk model shows high predictive value for abdominal wound dehiscence and may help to identify patients at increased risk.

Small stitches with small suture distances increase laparotomy closure strength.

BACKGROUND: There is no conclusive evidence which size of suture stitches and suture distance should be used to prevent burst abdomen and incisional hernia. METHODS: Thirty-eight porcine abdominal walls were removed immediately after death and divided into 2 groups: A and B (N = 19 each). Two suturing methods using double-loop polydioxanone were tested in 14-cm midline incisions: group A consisted of large stitches (1 cm) with a large suture distance (1 cm), and group B consisted of small stitches (.5 cm) with a small suture distance (.5 cm). RESULTS: The geometric mean tensile force in group B was significantly higher than in group A (787 N vs 534 N; P = .006). CONCLUSIONS: Small stitches with small suture distances achieve higher tensile forces than large stitches with large suture distances. Therefore, small stitches may be useful to prevent the development of a burst abdomen or an incisional hernia after midline incisions.

The value of combining anterior segment fluorescein angiography with indocyanine green angiography in scleral inflammation.

PURPOSE: To determine the value of anterior segment indocyanine green (ICG) angiography combined with anterior segment fluorescein angiography in scleral inflammation. DESIGN: Comparative observational case series. PARTICIPANTS: The study included 18 patients with various forms of scleral and episcleral disease and a single normal subject. METHODS: Anterior segment angiography using both ICG and fluorescein was performed to identify any vascular abnormalities and pathologic changes in the anterior segment. MAIN OUTCOME MEASURE: The pathologic criteria for anterior segment fluorescein angiography described by Watson and Bovey (1995) were used to compare and contrast the results of the angiograms. RESULTS: Fluorescein angiography and ICG angiography provide different and complementary information. Both dyes have different leakage patterns caused by their difference in optical and chemical properties. Areas of slow flow are more readily determined with fluorescein angiography. ICG angiography determines damage to and patency of individual vessels. CONCLUSION: Fluorescein angiography and ICG angiography detect areas of damage not clinically visible and can be useful in the differential diagnosis, the selection of appropriate medication, and monitoring and regulation of treatment in scleritis. To obtain the most information both investigations should be performed sequentially.