Rectus to defect ratio for estimating the complexity of ventral hernia repair: Is it reliable for robotic surgery?

INTRODUCTION: The rectus to defect ratio (RDR) has been previously described as a metric which enables surgeons to estimate the need to perform additional myofascial release (AMR), in addition to open Rives-Stoppa retro-muscular hernia repair. We sought to validate this measurement specifically for patients undergoing robotic totally extraperitoneal (eTEP) hernia repair. METHODS: A retrospective chart review of 188 patients who underwent robotic ventral hernia repair via eTEP approach. RDR on preoperative CT was compared to the final operation rendered. The primary endpoint was the RDR's ability to predict the need for TAR to achieve fascial closure. RESULTS: Of 188 patients, 154 were repaired with rectus myofascial release, while 34 also required TAR. There was a linear decrease in the need for TAR with increasing RDR. RDR 1-1.49 (n â€‹= â€‹12) required TAR in 66.7 â€‹% of cases, RDR 1.5-1.99 (n â€‹= â€‹25) in 43.8 â€‹%, RDR 2-2.49 (n â€‹= â€‹31) in 29 â€‹%, and RDR >2.5 (n â€‹= â€‹151) in just 5.8 â€‹% CONCLUSION: The RDR accurately predicts the need for TAR to achieve fascial closure during robotic eTEP ventral hernia repair. An RDR >2.5 portends fascial closure without TAR 94.2 â€‹% of cases.

One and done? Repair of recurrent hernias after prior Myofascial release.

BACKGROUND: Myofascial release (MFR) techniques, including retromuscular hernia repair, are often considered one-time repairs. We report recurrent ventral hernia repair (RVHR) in patients with prior MFR, focusing on redo-RM repair. METHODS: Retrospective analysis of all patients undergoing RVHR after prior MFR. Primary outcomes were operative time, surgical site infection (SSI), surgical site occurrence (SSO), and 20-month recurrence. RESULTS: 111 RVHR were performed after MFR. For patients with prior external oblique release (EOR, n = 31), transversus abdominis release (TAR) was used for repair in 13. For patients with prior TAR/PCS (posterior component separation) (n = 22), EOR (n = 2) and redo-TAR (n = 3) were employed with comparable results. Prior retromuscular (RM) repair was performed in 92 patients. Redo-RM (n = 32) and intraperitoneal onlay mesh (IPOM; n = 38) were most common. Operative time was longer for redo-RM. SSI (12.5 vs 7.9%), SSO (40.1 vs 39.5%), and recurrence (18.8 vs 16.2%) were similar for redo-RM and IPOM repair. CONCLUSION: RVHR after prior MFR does not preclude additional MFR. Redo-RM VHR outcomes are similar to those repaired with other techniques.

An Evaluation of Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative.

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Standard laparoscopic versus robotic retromuscular ventral hernia repair.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) demonstrates comparable recurrence rates, but lower incidence of surgical site infection (SSI) than open repair. Delayed complications can occur with intraperitoneal mesh, particularly if a subsequent abdominal operation is required, potentially resulting in bowel injury. Robotic retromuscular ventral hernia repair (RRVHR) allows abdominal wall reconstruction (AWR) and extraperitoneal mesh placement previously only possible with open repair, with the wound morbidity of LVHR. METHODS: All LVHR and RRVHR performed in our institution between June 2013 and May 2015 contained in the Americas Hernia Society Quality Collaborative database were analyzed. Continuous bivariate analysis was performed with Student's t test. Continuous nonparametric data were compared with Chi-squared test, or Fisher's exact for small sample sizes. p values <0.05 were considered significant. RESULTS: We compared 103 LVHR with 53 RRVHR. LVHR patients were older (60.2 vs. 52.9 years; p = 0.001), but demographics were otherwise similar between groups. Hernia width was similar (6.9 vs. 6.5 cm, p = 0.508). Fascial closure was achieved more often with RRVHR (96.2 vs. 50.5 %; p < 0.001) and aided by myofascial release in 43.4 %. Mesh was placed in an intraperitoneal position in 90.3 % of LVHR and extraperitoneal in 96.2 % of RRVHR. RRVHR operative time was longer (245 vs. 122 min, p < 0.001). Narcotic requirement was similar between LVHR and RRVHR (1.8 vs. 1.4 morphine equivalents/h; p = 0.176). Seroma was more common after RRVHR (47.2 vs. 16.5 %, p < 0.001), but SSI was similar (3.8 vs. 1 %, p = 0.592). Median length of stay was shorter after RRVHR (1 vs. 2 days, p = 0.004). Direct hospital cost was similar (LVHR $13,943 vs. RRVHR $19,532; p = 0.07). CONCLUSION: RRVHR enables true AWR, with myofascial release to offset tension for midline fascial closure, and obviates the need for intraperitoneal mesh. Perioperative morbidity of RRVHR is comparable to LVHR, with shorter length of stay despite a longer operative time and extensive tissue dissection.