Robotic transversus abdominis release using HUGO RAS system: our initial experience.

BACKGROUND: Transversus abdominis release (TAR) is an effective technique for treating large midline and off-midline hernias. Recent studies have demonstrated that robotic TAR (rTAR) is technically feasible and associated with improved outcomes compared to open surgery. There is no published experience to date describing abdominal wall reconstruction using the novel robotic platform HUGO RAS System (Medtronic®). METHODS: All consecutive patients who underwent a rTAR in our institution were included. Three of the four arm carts of the HUGO RAS System were used at any given time. Each arm configuration was defined by our team in conjunction with Medtronic® personnel. rTAR was performed as previously described. Upon completion of the TAR on one side, a redocking process with different, mirrored arms angles was performed to continue with the contralateral TAR. Operative variables and early morbidity were recorded. RESULTS: Ten patients were included in this study. The median BMI was 31 (21-40.6) kg/m2. The median height was 1.6 m (1.5-1.89 m). A trend of decreased operative time, console time, and redocking time was seen in these consecutive cases. No intraoperative events nor postoperative morbidity was reported. The median length of stay was 3 (1-6) days. CONCLUSION: Robotic TAR utilizing the HUGO RAS system is a feasible and safe procedure. The adoption of this procedure on this novel platform for the treatment of complex abdominal wall hernias has been successful for our team.

Role of diverting colostomy and reconstruction in managing Fournier's gangrene-a narrative review.

OBJECTIVE: To examine the role of bowel diversion and reconstructive surgeries in managing Fournier's gangrene (FG) to facilitate multidisciplinary collaboration between urologists, colorectal and plastic surgery teams. METHODS: A review of the literature was conducted using the databases Medline, Embase, PubMed in June 2023. The review included studies that evaluated the outcomes of FG following reconstructive surgeries or diverting colostomies. RESULTS: The existing evidence suggests that bowel diversion and colostomy formation could reduce the need for further debridement, shorten the time to wound healing, and facilitate skin graft or flap uptake in patients with FG. Additionally, the psychological impact of a stoma was shown not to be a major concern for patients. However, stoma carries a risk of perioperative complications and therefore may prolong the length of hospital stay. In reviewing the evidence for reconstruction in FG, large and deep defects seem to benefit from skin grafts or flaps. Noticeably, burial of testicles in thigh pockets has grown out of favour due to concerns regarding the thermoregulation of the testicles and the psychological impact on patients. CONCLUSION: The use of bowel diversion and reconstructive surgeries in managing FG is case dependent. Therefore, it is important to have close discussions with colorectal and plastic surgery teams when managing FG.

The Current Landscape of Prostate-Specific Membrane Antigen (PSMA) Imaging Biomarkers for Aggressive Prostate Cancer.

The review examines the vital role of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in the diagnosis, staging, and treatment of prostate cancer (PCa). It focuses on the superior diagnostic abilities of PSMA PET/CT for identifying both nodal and distant PCa, and its potential as a prognostic indicator for biochemical recurrence and overall survival. Additionally, we focused on the variability of PSMA's expression and its impact on personalised treatment, particularly the use of [177Lu] Lu-PSMA-617 radioligand therapy. This review emphasises the essential role of PSMA PET/CT in enhancing treatment approaches, improving patient outcomes, and reducing unnecessary interventions, positioning it as a key element in personalised PCa management.

Clinical Positron Emission Tomography/Computed Tomography: Quarter-Century Transformation of Prostate Cancer Molecular Imaging.

Although positron emission tomography/computed tomography (PET/CT) underwent rapid growth during the last quarter-century, becoming a new standard-of-care for imaging most cancer types, CT and bone scan remained the gold standard for patients with prostate cancer. This occurred as 2-fluorine-18-fluoro-2-deoxy-d-glucose was perceived to have a limited role owing to low sensitivity in many patients. A resurgence of interest occurred with the use of fluorine-18-sodium-fluoride PET/CT as a replacement for bone scintigraphy, and then choline, fluciclovine, and dihydrotestosterone (DHT) PET/CT as prostate "specific" radiotracers. The last decade, however, has seen a true revolution with the meteoric rise of prostate-specific membrane antigen PET/CT.

Comparison of 18F-based PSMA radiotracers with [68Ga]Ga-PSMA-11 in PET/CT imaging of prostate cancer-a systematic review and meta-analysis.

BACKGROUND: Prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) has become an increasingly established imaging modality in the staging of prostate cancer (PCa). Numerous PSMA-based tracers are currently available, however, there is a lack of consensus on the optimal radiotracer(s) for PSMA PET/CT. This study aims to investigate whether Fluorine-18 (18F)-labelled PSMA PET/CT is significantly different from Gallium-68 (68Ga) in primary diagnosis and/or secondary staging of prostate cancer following biochemical recurrence. METHODS: A critical review of MEDLINE, EMBASE, PubMed and Web of Science databases was performed in May 2023 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Studies that directly compared 18F-based PSMA radiotracers and [68Ga]Ga-PSMA-11 in terms of the normal organ SUV or the lesion SUV or the detection rate were assessed. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Twenty-four studies were analysed. [18F]DCFPyL and [18F]PSMA-1007 were the two most commonly studied 18F based PSMA tracers. [18F]JK-PSMA-7, [18F]rhPSMA-7, [18F]AlF-PSMA-11 were the new tracers evaluated in a limited number of studies. Overall, [18F]DCFPyL was observed to have a similar lesion detection rate to [68Ga]Ga-PSMA-11 with no increase in false positive rates. [18F]PSMA-1007 was found to have a greater local lesion detection rate because of its predominant hepatobiliary excretory route. However, [68Ga]Ga-PSMA-11 was observed to have a similar local lesion detection rate in studies that administer patients with furosemide prior to the scan. In addition, [18F]PSMA-1007 was found to have a significant number of benign bone uptakes. CONCLUSIONS: [18F]DCFPyL was observed to be similar to [68Ga]Ga-PSMA-11. [18F]PSMA-1007 was observed to be less preferrable to [68Ga]Ga-PSMA-11 due to its high benign bone uptakes. Overall, there was not enough evidence in differentiating the radiotracers based on their clinical impacts.

Fully resorbable poly-4-hydroxybutyrate (P4HB) mesh for soft tissue repair and reconstruction: A scoping review.

Background: Poly-4-hydroxybutyrate (P4HB) is a fully resorbable, biologically-produced polymer with a strength and flexibility comparable to permanent synthetic polymers. The objective was to identify/summarize all peer-reviewed publications involving P4HB mesh. Methods: A scoping review was conducted within PubMed and included articles published through October 2022. Results: A total of n = 79 studies were identified (n = 12 in vitro/bench; n = 14 preclinical; n = 6 commentaries; n = 50 clinical). Of the clinical studies, n = 40 reported results applicable to hernia and n = 10 to plastic/reconstructive surgery and involved patients of all Centers for Disease Control (CDC) wound classes and Ventral Hernia Working Group (VHWG) grades. Conclusion: P4HB mesh provides long-term hernia repair strength and exhibits promising clinical outcomes beyond its resorption period. Future studies should include randomized controlled trials comparing P4HB to other biomaterials, as well as optimal patient selection, operative technique, long-term outcomes, minimization of potential mesh-related complications, and potential contraindications/complications for P4HB in hernia/abdominal wall reconstruction.

The Role of Releasing Incisions in Emergency Inguinal Hernia Repair.

The majority of inguinal hernia repairs worldwide are performed on an outpatient basis. However, incarceration and concern for strangulation of abdominal contents necessitates emergent repair in order to address visceral ischemia. In the setting of salvageable ischemia, this necessitates release of strangulation of blood supply by the hernia defect and reduction of visceral contents into the abdominal cavity. In certain cases, this cannot be achieved with simple manual reduction, and requires enlargement of the aperture of the hernia defect with releasing incisions in order to allow reduction. We aim to describe strategies for releasing incisions via open, laparoscopic, and robotic approaches in emergency inguinal hernia repair.

The Voodoo that We Do: Controversies in General Surgery.

Incisional hernia remains a common complication following abdominal surgery, and its incidence can be reduced with standardized wound closure techniques. Robust evidence exists to support certain fascial closure methods, such as using a small bites, 4-to-1, continuous slow absorbable suture technique for elective midline laparotomies. On the other hand, there are other common surgical practices that lack quality data to support their routine use, such as abdominal binders, negative-pressure wound therapy, and reapproximation of subcutaneous tissue.

General Surgery: Management of Postoperative Complications Following Ventral Hernia Repair and Inguinal Hernia Repair.

Ventral and inguinal hernia repairs are some of the most commonly performed general surgery operations worldwide. This review focuses on the management of postoperative complications, which include surgical site infection, hernia recurrence, postoperative pain, and mesh-related issues. In each section, we aim to discuss classifications, risk factors, diagnostic modalities, and treatment options for common complications following hernia repair.

A novel endoscope-assisted technique for lateral lumbar interbody fusion: feasibility study, technical note, and operative video.

The lateral approach to the spine is generally well tolerated, but reports of debilitating injury to the lumbar plexus, iliac vessels, ureter, and abdominal viscera are increasingly recognized, likely related to the lack of direct visualization of these nearby structures. To minimize this complication profile, the authors describe here a novel, minimally invasive, endoscope-assisted technique for the LLIF and evaluate its clinical feasibility. Seven consecutive endoscope-assisted lateral lumbar interbody fusion (LLIF) procedures by the senior authors were reviewed for the incidence of approach-related complications. One patient had a postoperative approach-related complication. This patient developed transient ipsilateral thigh hip flexion weakness that resolved spontaneously by the 3-month follow-up. No patient experienced visceral, urological, or vascular injury, and no patient sustained a permanent neurological injury related to the procedure. The authors' preliminary experience suggests that this endoscope-assisted LLIF technique may be clinically feasible to mitigate vascular, urological, and visceral injury, especially in patients with previous abdominal surgery, anomalous anatomy, and revision operations. It provides direct visualization of at-risk structures without significant additional operative time. A larger series is needed to determine whether it reduces the incidence of lumbar plexopathy or visceral injury compared with traditional lateral approaches.

Sex Differences, Sleep Disturbance and Risk of Persistent Pain Associated With Groin Hernia Surgery: A Nationwide Register-Based Cohort Study.

Persistent pain after groin hernia repair is a major health problem. Sleep disturbance is associated with heightened pain sensitivity. The main objective of this study was to examine the role of sleep disturbance in the development and long-term maintenance of chronic postherniorrhaphy inguinal pain (CPIP), with exploration of sex differences. From 2012 to 2017, a national cohort of patients with prior groin hernia repair (n = 2084;45.8% females) were assessed for the development of CPIP 12 months after surgery. Patients then underwent long-term (median 5.0 years) follow-up to evaluate the contribution of sex and sleep disturbance on the maintenance of CPIP. Associations between pre- and postoperative sleep problems (assessed at long-term follow-up) and CPIP were tested using logistic regression. Females had higher rates of CPIP with negative impact on daily activities 12 months after surgery as compared to males (14.6 vs 9.2%, P < .0005), and were more likely to have moderate-severe CPIP in the long-term (3.1 vs 1.2%, P = .003). Preoperative sleep problems predicted development of CPIP 12 months after surgery (adjusted odds ratio [aOR] 1.76 [95%CI 1.26-2.46], P = .001) and CPIP in the long-term (aOR 2.20 [1.61-3.00] , P < .0001). CPIP was associated with insomnia and depression. Sleep disturbance may increase the risk for CPIP, and contribute to maintenance of postsurgical pain. PERSPECTIVE: Females are at heightened risk for CPIP as compared to males. Increased severity of pain symptoms are linked to poorer sleep and psychiatric morbidity. Given the robust associations between sleep disturbance and CPIP, interventions which consolidate and promote sleep, especially in females, may improve long-term pain control.

Intra-Operative Vascular Injury and Control During Laparoscopic and Robotic Mesh Explantation for Chronic Post Herniorrhaphy Inguinal Pain (CPIP).

INTRODUCTION: Chronic postherniorrhaphy inguinal pain (CPIP) is common following inguinal hernia repair. As even primary minimally-invasive inguinal hernia repairs carry a risk of significant intra-operative bleeding, it is unsurprising that reoperative groin exploration and mesh explantation for chronic post-inguinal herniorrhaphy pain confers an even higher risk of arteriotomy or venotomy due to a distorted anatomy and the presence of adhesions. In this report, we present a single institution's experience with the management of intra-operative vascular injury encountered during minimally invasive groin exploration and mesh explantation for CPIP. MATERIALS AND METHODS: We performed a retrospective consecutive case series study at a single academic center of patients with CPIP who underwent minimally invasive groin exploration and mesh removal during which an iatrogenic arteriotomy or venotomy occurred from September 2015 to September 2020. Descriptive statistics were collected for age, laterality of hernia repair, mean follow-up time, surgical approach (robotic vs. laparoscopic), type of intra-operative vascular injury, vascular control technique, and post-operative complications. RESULTS: Of 196 minimally invasive groin exploration and mesh removal cases, 46 were performed with robotic assistance and 150 were performed using traditional laparoscopy. The overall incidence of intra-operative vascular injury was 43 (22%). Fifteen of 46 (32%) robotic groin exploration and mesh removal cases and 28 of 150 (19%) laparoscopic cases involved vascular control. Three of 15 (20%) robotic cases and 23 of 28 (82%) laparoscopic cases involved a hybrid open inguinal approach to address anterior pathology (neurectomy, anterior mesh removal, hernia repair) or facilitate exposure for vascular repair. The most common site of injury was the inferior epigastric vessels. Other sites included the iliac vein, iliac artery, corona mortis, and accessory obturator vessels. Vascular control techniques included ligation with an energy device or suture, primary suture repair of injured vessel, or bovine pericardium patch angioplasty. All were managed without intra-operative vascular surgery intervention except for one case with extensive calcification that required endarterectomy and angioplasty to improve patency. No cases required conversion to midline laparotomy. Ninety three percent of the cases with large vessel bleeding during laparoscopic-assisted procedures were repaired via an open groin incision, whereas all cases of large vessel bleeding during robotic-assisted procedures were repaired robotically. None of the patients required transfusion. Postoperative complications occurred in 3 patients (7%), 2 (5%) developed hematoma formation requiring surgical evacuation, and 1 (2%) developed ipsilateral iliofemoral deep vein thrombosis (DVT) and underwent peripheral angiography and thrombolysis. CONCLUSIONS: Although minimally invasive groin exploration and mesh explantation for CPIP is technically challenging, it is a safe and effective operation when performed at experienced centers. Iatrogenic vascular injury should be anticipated but can be effectively controlled laparoscopically, robotically, or via a hybrid open inguinal incision without conversion to a midline laparotomy and with low post-operative complication rates.

A Simplified clinical algorithm for standardized surgical treatment of chronic pain after inguinal hernia repair: A quality assessment study.

BACKGROUNDS: The optimal surgical strategy for the treatment of chronic pain after inguinal hernia repair is controversial and based on relatively weak evidence. The purpose of this study was to analyze pain-related functional impairment using a simplified clinical treatment algorithm for a standardized surgical treatment. The algorithm was predefined, and the indication to operate was based on strict criteria. METHODS: This was a prospective, non-controlled, explorative study. The pain operation was either open triple neurectomy with total mesh removal or laparoscopic retroperitoneal triple neurectomy. A clinically relevant postoperative change was defined as ⩾25% change from the baseline level. Primary outcome was pain-related impairment of physical function using the Activity Assessment Scale. Secondary outcomes included Individual Patient-Reported Outcome Measures, Hospital Anxiety and Depression Scale, and PainDETECT Questionnaire. RESULTS: A total of 240 patients were referred (2016-2019). Sixty-six patients were included for the analysis. A total of 25% of referred patients were offered a pain operation. Follow-up was a median 3 months (range: 3-13). Activity Assessment Scale scores were clinically relevant improved in 43 patients (68%), not clinically relevant different in 19 (30%), and clinically relevant worsened in one (2%). Secondary outcome scores were all significantly improved (P < 0.05) except for the risk of postoperative depression (P = 0.092). Fifty-one patients (77%) reported that chronic groin pain was reduced after the operation. CONCLUSIONS: Pain-related functional impairment was improved with clinical relevance in roughly 70% of patients through a simplified clinical algorithm for surgical treatment of severe chronic pain after an inguinal hernia repair.