Concordance of financial disclosures among faculty at the 2018-2020 SAGES annual meetings.

BACKGROUND: Financial relationships with industry may bias educational content delivered by physicians. SAGES strives to mitigate potential bias, relying on physician self-reporting. Retrospective review of relationships is possible using the Open Payments Database (OPD), a public record of industry-reported payments to US physicians. We aimed to evaluate the effectiveness of the SAGES disclosure process by comparing faculty disclosures to SAGES, faculty disclosures within presentations, and OPD records among speakers at the 2018-2020 SAGES meetings. METHODS: We reviewed all presentations from the SAGES 2018-2020 Annual Meetings. For each invited presentation, all slide-disclosed relationships were recorded. For US physicians, we queried the OPD and recorded relationships ≥ $500 USD in the calendar year prior to presentation. We compared the slide-disclosed relationships with OPD-reported relationships and with those provided to SAGES during the faculty disclosure process. We surveyed a sample of the 2020 annual meeting speakers to analyze potential reasons for discordance. RESULTS: From 2018 to 2020, there were 1,355 invited presentations, of which 1,234 (91%) were available for review. Disclosure slides were present in 1,098 (89%), increasing from 86% in 2018 to 93% in 2020. The proportion of speakers with OPD-reported relationships ≥ $500 increased from 54% in 2018 to 66% in 2020. The total value of OPD relationships decreased from $5.9 million (2018) to $3.3 million (2020) with a concomitant decrease in the proportion with high discordance from 9% in 2018 to 5% in 2020. Among the 2020 speakers with high discordance, the most common explanations for discordance were being unaware of payment or payment outside the 12-month timeframe (55%). CONCLUSIONS: Discordance between financial disclosures reported to SAGES and OPD highlight the need for improvements in the faculty disclosure process. SAGES will continue to streamline this process by incorporating faculty review of their OPD disclosures to ensure all educational programs remain free of commercial bias.

Hiatal hernia repair with biosynthetic mesh reinforcement: a qualitative systematic review.

INTRODUCTION: Reinforcement of crural closure with synthetic resorbable mesh has been proposed to decrease recurrence rates after hiatal hernia repair, but continues to be controversial. This systematic review aims to evaluate the safety, efficacy, and intermediate-term results of using biosynthetic mesh to augment the hiatus. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed throughout this systematic review. The Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias in Randomized Trials tools were used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study design, risk of bias, publication bias, and statistical analysis. RESULTS: The systematic literature search found 520 articles, 101 of which were duplicates and 355 articles were determined to be unrelated to our study and excluded. The full text of the remaining 64 articles was thoroughly assessed. A total of 18 articles (1846 patients) were ultimately included for this review, describing hiatal hernia repair using three different biosynthetic meshes-BIO-A, Phasix ST, and polyglactin mesh. Mean operative time varied from 127 to 223 min. Mean follow up varied from 12 to 54 months. There were no mesh erosions or explants. One mesh-related complication of stenosis requiring reoperation was reported with BIO-A. Studies showed significant improvement in symptom and quality-of-life scores, as well as satisfaction with surgery. Recurrence was reported as radiologic or clinical recurrence. Overall, recurrence rate varied from 0.9 to 25%. CONCLUSION: The use of biosynthetic mesh is safe and effective for hiatal hernia repair with low complications rates and high symptom resolution. The reported recurrence rates are highly variable due to significant heterogeneity in defining and evaluating recurrences. Further randomized controlled trials with larger samples and long-term follow-up should be performed to better analyze outcomes and recurrence rates.

Assessing outcomes in laparoscopic vs open surgical management of adhesive small bowel obstruction.

BACKGROUND: Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. METHODS: This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. RESULTS: The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6 days, p = 0.001) and median length of stay (8 vs 13 days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7 days, p = 0.06) and shorter overall length of stay (10 vs 16 days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5 days, p < 0.0009) and length of stay (7 vs 10 days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. CONCLUSION: Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.

Primary abandon of hernia sac for inguinoscrotal hernias: a safe way to cut corners.

INTRODUCTION: Inguinoscrotal hernias (ISH) pose a challenge to surgeons with consistently higher rates of postoperative complications and recurrence rates. The aim of this study is to report our initial experience and early results with a new technique for inguinoscrotal hernia repair. METHODS: A review of a prospectively maintained multi-center database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias from March 2021 to July 2022. Demographics and outcomes were analyzed. Univariate analysis and multivariate logistic regression were performed. RESULTS: A total of 76 minimally invasive inguinal hernia repairs were performed. In 70 patients (92%) C-PAS was used as the technique to abandon the sac while in the remaining 6 patients, "pirate-eye-patch" technique was used. Median hernia ring was 3 (IQR 2.5-3.5) cm and median hernia sac was 9.5 (8-10.8) cm. Median operative time was 70 min (IQR 56-96). Seroma was present in 22 (28.9%) patients 7 days after surgery. Most had seroma only in the inguinal area (n = 19; 25%). Thirty days after surgery, 12 (15.8%) patients still had seroma in the inguinal area and 6 (7.9%) in the inguinoscrotal area. Ninety days after surgery, four (5.3%) patients had inguinal seroma, 2 (2.6%) scrotal seromas and 3 (3.9%) inguinoscrotal seromas. The size of the hernia sac was not associated with seroma formation 7 days after surgery (OR 1.06; 95% CI 0.89-1.2; P = 0.461) in the multivariate logistic regression. BMI was also not associated with seroma formation (OR 0.8; 95% CI 0.74-1.06; P = 0.2). CONCLUSIONS: Planned abandon of the hernia sac is an interesting alternative and is associated with a low rate of complications and acceptable seroma formation rates.

Analysis of Outpatient Adherence in 45,237 Patients Referred by an Emergency Department to Surgical Clinics.

INTRODUCTION: This study examines referral patterns to surgical clinics from the emergency department and the impact of sociodemographic factors on adherence. METHODS: Patients from 2017 to 2021 were identified who had a referral placed to surgical specialties from the ED. The primary outcome was the proportion of patients who had a referral to surgery placed during an ED visit but who showed up to surgery clinic visit within 60 days of referral placement. Univariate and multivariate analysis was performed. RESULTS: Referrals were made for 45,237 patients overall and 4130 for general surgery specifically. 44% showed up to general surgery clinic visit. In univariate and multivariate analysis, those who showed up to clinic were older, tended to be female, had a lower social economic status, had Medicaid or Medicare insurance and had more comorbidities compared to those who did not show up. Asians and Hispanics were more likely to show up to clinic compared to Whites. CONCLUSIONS: Assigning navigators in the ED to follow-up with patients who are younger and healthier, with private insurances who have existing PCPs to ensure they follow up as advised is a potential targeted intervention to improve clinic adherence.

A Novel Polypropylene Mesh (T-Line®) for Abdominal Wall Repair: Early Experience at Three Centers in the United States.

Mesh suture was initially developed and investigated to overcome suture pull-through in hernia repair. It has a large area compared to standard suture which distributes the load in tissue, reducing stress at the suture/tissue interface and preventing suture from cutting through tissue or the mesh. This report describes our early experience using the new T-line® mesh (Deep Blue Medical Advances, Durham, NC, USA) in patients with incisional and primary ventral hernia repairs. This is a descriptive, retrospective study in 18 patients who underwent abdominal wall repair with T-Line® mesh from November 2020 to November 2021 in three academic centers. T-Line® is a novel moderate-weight macroporous, polypropylene mesh with extensions that are 29 times the cross-sectional area of #0 polypropylene suture. They can be sewn into fascia to anchor the mesh with no need for suture tackers or other devices to fixate the mesh. The median age of the patients was 56.5 years (range 25-83) and the median BMI was 31.7 kg/m2 (range 23.6-51). Twelve patients (66.7%) had primary hernias, and 11 (61.1%) had a recurrent hernia. The median defect area was 117.5 cm2 (range 4-390) and the median mesh area was 449.5 cm2 (range 130-600). The mesh position was onlay in 16 cases (88.9%) and sublay in 2 cases (11.1%). The median operative time was 247 minutes (range 104-395). The median length of stay was six days (range 0-21) with no significant in-hospital complications. One patient had a surgical site infection (5.5%) and two patients developed seromas (11.1%). There were no early hernia recurrences with a median follow-up of 28 days (range 8-307). The T-Line® mesh was shown to be safe and effective for patients with ventral hernia in the short term.

Robotic mesh explantation (RoME): a novel approach for patients with chronic pain following hernia repair.

BACKGROUND: Post-herniorrhaphy pain is common with an estimated 8-10% incidence of mesh-related complications, requiring mesh explantation in up to 6% of cases, most commonly after inguinal hernia repairs. Reoperation for mesh explantation poses a surgical challenge due to adhesions, scarring and mesh incorporation to the surrounding tissues. Robotic technology provides a versatile platform for enhanced exposure to tackle these complex cases. We aim to share our experience with a novel robotic approach to address these complex cases. METHODS: A descriptive, retrospective analysis of patients undergoing a robotic mesh explantation (RoME) for mesh-related chronic pain, or recurrent ventral hernia by two surgeons between the period of March 2016 and January of 2020. The patients were evaluated for resolution of mesh related abdominal pain as well as early post-operative complications. RoME was performed with concomitant hernia repair in cases of recurrences. RESULTS: Twenty-nine patients underwent a robotic mesh explantation (RoME) for mesh-related chronic pain, or recurrent ventral hernia between March 2016 and January of 2020. Nineteen patients (65.5%) had a prior inguinal hernia repair and 10 patients (34.5%) had a prior ventral hernia repair. Indications for mesh removal included chronic pain with or without hernia recurrence. Seventeen patients (58.6%) reported improvement or resolution of pain postoperatively (63% with a prior inguinal hernia repair and 50% of patients with a prior ventral hernia repair). Five patients (17.2%) required mesh reinforcement after explantation. Nineteen patients (65.5%) underwent mesh explantation with primary fascial closure or no mesh reinforcement. The mean follow-up was 36.4 days. The most common postoperative complication was seroma formation (6.8%), with one reported recurrence (3.4%). CONCLUSION: Robotic mesh explantation in challenging cases due to the effect of chronic scarring, adhesions and mesh incorporation to the surrounding tissues is safe and provides an advantageous platform for concomitant hernia repair in these complex cases.

Social media as a tool for surgical education: a qualitative systematic review.

BACKGROUND: Social media use has exploded, attaining a significant influence within medicine. Previous studies have denoted the use of social media in various surgical specialties as a means to exchange professional ideas and improve the conference experience and at the same time, some have assessed its feasibility as a method of education. This systematic review aims to characterize the use of social media as a tool for general surgery education. METHODS: A systematic review of several databases from each database inception was conducted following the PRISMA guidelines. The JBI's critical appraisal tools were used to assess quality of the studies. RESULTS: A total of 861 articles were identified of which 222 were duplicates removed. The titles and abstracts from the remaining 639 abstracts were screened and 589 were excluded. The remaining 51 full articles were analyzed for eligibility, of which 24 met inclusion criteria and were included in the systematic review. These studies covered the general surgery specialty, of which 11 (n = 46%) focused on the laparoscopic surgical approach, 1 (n = 4%) on robotic-assisted surgical procedures, 1 (n = 4%) on both surgical approaches previously mentioned and 11 (n = 46%) on the general surgery specialty regardless of the surgical approach or technique. CONCLUSIONS: Advantages that SM offers should be considered, and content creators and institutions should help collectively to make sure that the content being published is evidence and guideline-based so its use it is taken to the maximum benefit.

Weight loss one year after laparoscopic roux-en-Y gastric bypass is not dependent on the type of gastrojejunal anastomosis.

BACKGROUND: Laparoscopic roux-en-Y gastric bypass (LRYGB) is the gold standard weight-loss procedure. There are different techniques to perform the gastrojejunal (GJ) anastomosis, but there is no consensus as to which one is superior for weight loss. Our goal in this study was to assess one-year weight loss after LRYGB comparing the three different techniques at our tertiary care center. METHODS: The American college of surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®) data for Montefiore Medical Center for years 2014-2017 were analyzed. Three surgeons were included in this study; each type of anastomosis was performed by a single surgeon. Patients were included if they underwent primary LRYGB. Patients were designated to one of three different groups depending of the type of gastrojejunal anastomosis performed: hand sewn, circular stapled, or linear stapled. One-year weight loss was assessed as primary endpoint of the study. A descriptive analysis of perioperative variables for each group was included as well. RESULTS: A total of 1011 patients underwent primary LRYGB. 429 (42.1%) were performed with circular-stapled GJ anastomosis, 433 (42.5%) with a hand-sewn GJ anastomosis, and 149 (14.6%) linear-stapled GJ anastomosis. The median BMI was 46.08  ±  6.43, with no difference between groups (p = .405). Procedure time was 106.70  ±  28.23 min for the circular group, 108.27  ±  28.59 min for the hand-sewn group, and 115.78  ±  36.11 min for the linear group (p > 0.005). There were no significant differences in complications except for the need of postoperative transfusions (p < 0.002). There was no statistically significant difference in %EWL one year after surgery: %EWL was 58.81  ±  16.54 kg for hand sewn, 58.86  ±  14.84 kg for circular, and 59.20  ±  17.58Kg for linear. (p = .595). CONCLUSION: There is no difference in weight loss one year after LRYGB based on the type of gastrojejunal anastomosis performed.

Diagnosis of COVID-19 and the bariatric surgery population: a single center experience.

BACKGROUND: While many cases of the coronavirus disease 2019 (COVID-19) are mild, patients with underlying medical conditions such as hypertension (HTN), diabetes mellitus (DM), older age, and morbid obesity are at higher risk of hospitalization and death. These conditions are characteristic of patients eligible for bariatric surgery, many of whom underwent weight loss procedures in the months prior to cessation of elective surgery in March 2020. The effects of the virus on these high-risk patients who had increased healthcare exposure in the early days of the pandemic are currently unknown. OBJECTIVES: To describe the experience of patients who underwent bariatric surgery during the early evolution of the COVID-19 pandemic. METHODS: This is a cross-sectional study including patients from a single center who underwent bariatric surgery from January 1st, 2020 to March 18th, 2020. A database was created to analyze patients' demographics, operative variables, and postoperative outcomes. All patients were contacted and a telephone survey was completed to inquire about COVID-19 exposure, symptoms, and testing 30 days before and after surgery. RESULTS: A total of 190 patients underwent bariatric surgery during the study period. Laparoscopic sleeve gastrectomy was the most common procedure (71.6%). One hundred seventy-eight patients (93.7%) completed the telephone survey. Postoperatively, 19 patients (10.7%) reported COVID-19 compatible symptoms, and six patients (3.4%) went on to test positive for COVID-19. There were no COVID-19-related hospital admissions or mortalities in this population. CONCLUSIONS: Morbidly obese patients are at high risk of severe disease secondary to COVID-19, and those undergoing bariatric surgery during the evolution of the pandemic reported symptoms at a rate of 10.7% 30 days after the surgery. While none of these patients suffered severe COVID-19 disease, the temporal relationship of their symptomatology and increased exposure to the healthcare system as a result of their surgery suggest an increased risk of disease with elective surgery.

Implementation of the Versius Surgical System in Complex Abdominal Wall Repair: First Reported Case of an Robotic ETEP/TAR Procedure.

BACKGROUND: Robotic ventral hernia repair has been increasing globally, with comparable outcomes to laparoscopic repair and lower rates of conversion to open surgery. Robotic surgery is increasing in popularity, and there is a number of new robotic systems entering the marketing. We report the first case of a Roboic eTEP using the Versius robotic system in a patient with an incisional hernia. METHODS: Surgery was performed using the Versius system from CMR surgical which consists of bedside units for each instrument and a console. The patient presented with an incisional hernia measuring 9.5×5 cm in the left flank. RESULTS: The patient was discharged on postoperative day (POD) 2 with a drain. There was no need for opioids. The drain was removed at POD 7. The patient presented at POD 10 with erythema and cellulitis in the area that previously had tape on it, and it was resolved with a short course of oral antibiotics. CONCLUSION: The eTEP technique for hernia surgery was safe and feasible using the Versius robotic system. Implementation is possible in experienced hands with minimal changes to the surgical techniques.

Hybrid intraperitoneal onlay mesh repair for incisional hernias: a systematic review and meta-analysis.

INTRODUCTION: Laparoscopic IPOM is technically challenging, especially regarding fascial closure. Hybrid repair has been proposed as a simpler approach. We aimed to compare hybrid and laparoscopic intraperitoneal onlay mesh repair (IPOM) in patients undergoing ventral hernia repair (VHR). METHODS: We performed a systematic review of Cochrane, Scopus, and MEDLINE databases to identify studies comparing hybrid versus laparoscopic IPOM VHR reporting the outcomes of recurrence, mortality, seroma, postoperative complications, reoperation, surgical site infection, and operative time. Statistical analysis was performed using RStudio 4.1.2 using a random-effects model. RESULTS: We screened 2,896 articles and fully reviewed 22 of them. A total of five studies, encompassing 664 patients were included. Among them, 337 (50.8%) underwent laparoscopic IPOM. All patients had incisional hernias, with a mean diameter varying from 3 to 12.7 cm, 60% were women, with a mean BMI varying from 29.5 to 38. The hybrid approach had a lower rate of seroma when compared to the laparoscopic (OR 0.22; 95% CI 0.05 to 0.92; p = 0.038; I²=78%). We found no difference in recurrence, mortality, postoperative complications, reoperation, surgical site infection, and operative time between groups. CONCLUSION: Hybrid IPOM is a safe and effective method for incisional hernia repair. Moreover, it facilitates fascial defect closure and decreases postoperative seromas.

Current trends and outcomes for unilateral groin hernia repairs in the United States using the Abdominal Core Health Quality Collaborative database: A multicenter propensity score matching analysis of 30-day and 1-year outcomes.

BACKGROUND: Different unilateral groin hernia repair approaches have been developed in the last 2 decades. The most commonly done approaches are open inguinal hernia repair by the Lichenstein technique, laparoscopic approach by either total extraperitoneal or transabdominal preperitoneal, and robotic transabdominal preperitoneal approach. Hence, this study aimed to compare early and late postoperative outcomes in patients who underwent unilateral robotic transabdominal preperitoneal, laparoscopic transabdominal preperitoneal, and laparoscopic total extraperitoneal, and open groin hernia repair using a United States national hernia database, the Abdominal Core Health Quality Collaborative Database. METHODS: Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent elective unilateral groin hernia repair from 2015 to 2022, with a 1:1 propensity score match analysis conducted for balanced groups. The univariate analysis compared the groups across the preoperative, intraoperative, and postoperative timeframes. RESULTS: The Abdominal Core Health Quality Collaborative database identified 14,320 patients who underwent elective unilateral groin hernia repair and had documented 30 days of follow-up. Propensity score matching stratified 1,598 patients to each group (total of 6,392). The median age was 64 years (interquartile range 53-74) for open groin hernia repair, whereas 60 (interquartile range 47-69) for laparoscopic transabdominal preperitoneal, 62 (interquartile range 48-70) for laparoscopic total extraperitoneal, and 60 (interquartile range 47-70) for robotic transabdominal preperitoneal were noted. Open groin hernia repair had more American Society of Anesthesiologists score 4 (52, 3%) patients (P < .001). A painful bulge was the most common indication (>85%). Operating room time >2 hours was more significant in the robotic transabdominal preperitoneal group (123, 8%; P < .001). Seroma rate was higher in the laparoscopic transabdominal preperitoneal (134, 8%; P < .001). A 1-year analysis had 1,103 patients. Hematoma, surgical site infection, readmission, reoperation, and hernia recurrence at 30 days or 1 year did not differ, with an overall recurrence rate of 6% (n = 67) at 1 year (P = .33). In patients with body mass index ≥30 kg/m2, the robotic approach had lower rates of surgical site occurrence (n = 12, 4%; P = .002) and seroma (n = 5, 2%; P < .001) compared with the other groups. When evaluating recurrence 1 year after surgery, the robotic transabdominal preperitoneal group had 10% versus 18% open groin hernia repair, 11% laparoscopic transabdominal preperitoneal, and 18% laparoscopic total extraperitoneal, but it was not statistically significant (P = .53). CONCLUSION: There was no difference in readmission, reoperation, and surgical site infection among the surgical techniques at 30 days. However, laparoscopic transabdominal preperitoneal was associated with more seromas. Hernia recurrence at 1 year was similar across groups; the robotic approach had the lowest recurrence rate among all 3 repairs but did not reach statistical significance. The robotic approach performed better in patients with a body mass index of 30 kg/m2 for surgical site occurrence and seroma than in other surgical techniques.

Twitter and surgery: how social media can impact surgical education.

INTRODUCTION: Social media is now a ubiquitous form of communication. It has allowed individuals to connect and share ideas across the country and across the globe. Twitter allows user to share thoughts in 280-character "tweets," while also connecting these messages to community posts with hashtags. While the surgical community utilizes many social media platforms; the use of Twitter has been particularly unique. The aim of this review was to focus on several areas of Twitter utilization in surgery including: surgical education, residency training, and utilization by surgical societies. EVIDENCE ACQUISITION: The following databases were searched for studies meeting our inclusion criteria: MEDLINE, Embase, Cochraine library, ScieLO, LILACS. EVIDENCE SYNTHESIS: Selected papers discussed the use of Twitter for surgical education, social media use by residency programs, and social media use by surgical societies. CONCLUSIONS: Twitter has allowed for growth of the surgical community both locally and nationally. It allows for promotion and connectivity for surgical departments and individual surgeons. Furthermore, it is an important communication tool for surgical societies to reach members and disseminate guidelines and recommendations.

Learning Curve of Robotic Enhanced-View Extraperitoneal Approach for Ventral Hernia Repairs.

Introduction: The enhanced-view extraperitoneal (eTEP) technique was first described for minimally invasive inguinal hernia repairs and later for laparoscopic ventral hernia repair. The objective of this study was to report our early experience and learning curve (LC) with the robotic-assisted eTEP (R-eTEP) approach. Materials and Methods: We performed a retrospective analysis of patients undergoing R-eTEP repair for ventral hernias from December 2018 to September 2021. A single surgeon operative time (OT)-based LC was evaluated. Results: A total of 81 patients underwent an R-eTEP from December 2018 to September 2021. Sixty-five patients were ultimately included in our analysis. Fifty-seven patients underwent eTEP-Rives-Stoppa (RS) and 8 patients underwent eTEP-transversus abdominis release (TAR). The median age in the whole cohort was 57 years (interquartile range [IQR] 51.5-64.5 years) with no difference between the groups. The median body mass index (BMI) was 31 kg/m2 (IQR 27-34.7 kg/m2) in the eTEP-RS group and 29.7 kg/m2 (IQR 28.5-31 kg/m2) in the eTEP-TAR group. There were 36 incisional hernias (63%) in the eTEP-RS group and 8 (100%) in the eTEP-TAR group. There were 14 recurrent hernias (25%) in the eTEP-RS group and 2 (25%) in the eTEP-TAR group. The LC was evaluated only in the eTEP-RS cases. We divided the cohort into 3 chronological groups (G1, G2, and G3), including 19 cases each. The median OT in each group was 177 (IQR 147-200), 153 (IQR 127-187), and 125 minutes (IQR 106-152 minutes), respectively. There was no difference in the median OT between G1 and G2 (P = .390). G3 had a shorter median OT than G2 (P = .02) and G1 (P = .001). There was no difference between these groups in median age, BMI, defect area, defect width, and mesh area. Conclusions: The R-eTEP approach has been shown to be safe and feasible for ventral and incisional hernia repairs. A statistically significant decrease in OT was observed after 38 cases.

Incarcerated Epiploic Appendix in a Spigelian Hernia Treated by Robotic-Assisted Surgery.

Introduction: We report a case of a patient who presented with incarceration of the epiploic appendix in a spigelian hernia, subsequently treated by a robotic-assisted surgical approach. Case Description: This is a case of a 52 year-old male patient who presented with nausea and two-week history of worsening left lower quadrant pain. On examination, the patient had an irreducible left lower quadrant mass. Computed tomography scan showed an epiploic appendagitis in a left Spigelian hernia. The patient underwent a robotic transabdominal preperitoneal hernia repair successfully and was discharged home the same day. Conclusion: The robotic platform was a safe and effective approach to treating the patient with no postoperative complications.

The Influence of Pregnancy on Weight Loss After Previous Bariatric Surgery.

Introduction: Bariatric surgery is routinely performed on obese women of reproductive age, most commonly with the laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass procedures (RYGB). This study analyzes the effects of postoperative pregnancy on excess BMI loss percentage (EBMIL%) after SG and RYGB. Methods: A retrospective study was conducted with 191 female patients of reproductive age between 20 and 40 years who underwent SG and RYGB performed at our institution between January 2017 and December 2018. A comparison of the results at 4-year follow-up was performed between patients who became pregnant after bariatric surgery with patients who did not. Results: Among 191 total cases, 32 (16.7%) patients became pregnant within a 4-year follow-up period, and 159 (83.2%) patients did not. The median postoperative body mass index (BMI) in the pregnant group was 33.3 kg/m2 (interquartile range [IQR] 30.1-38.5) and 33.5 kg/m2 (IQR 28.9-38.6) in the nonpregnant group. The mean EBMIL% within a 4-year follow-up in the pregnant group was 50.4% (standard deviation [SD] 23.5) and 55.5% (SD 30.4) in the nonpregnant group. The median weight before surgery in the pregnant group was 112 kg (IQR 107.9-132.2) and 117 kg (IQR 106-132.5) in the nonpregnant group. The median weight after surgery in the pregnant group was 89.5 kg (IQR 79.5-111) and 88.9 kg (IQR 78-103) in the nonpregnant group. There was no significant difference between outcomes. Conclusion: Weight loss maintenance after bariatric surgery is not impacted by postoperative pregnancy within a 4-year follow-up after SG and RYGB.

Outcomes in Minimally Invasive Sleeve Gastrectomy and Implications for Surgical Resident Education.

Introduction: Resident participation in advanced minimally invasive and bariatric surgeries is controversial. The aim of this study is to evaluate the safety of resident participation in robotic and laparoscopic sleeve gastrectomy (SG). Methods: Prospectively maintained institutional Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database was used to identify patients who underwent SG, which was performed at our institution between January, 2018, and December, 2021. Operative notes were reviewed to determine the training level of the assistant. These were then classified into 7 groups: postgraduate years 1-5 residents, bariatric fellow (6), and attending surgeons (7). Each group was stratified and their outcomes, which included duration of surgery, length of stay (LOS), postoperative complications, readmissions, and reoperations, were compared. Results: Out of 2571 cases, the assistants for the procedures were minimally invasive surgery (MIS) fellows (n = 863, 58.8%), fifth- and fourth-year residents (n = 228, 15.5%), third- and second-year residents (n = 164, 11.2%), no assistants (n = 212, 14.5%), and 134 robotic SG. Mean body mass index was higher in cases wherein the attending surgeon performed by himself (47.1, standard deviation 7.7) when compared with other groups. There were no conversions to open. Mean LOS was 1.3 days, and there was no difference between groups (P = .242). Postoperative complications were low, with 11 reoperations in 30 days (3.3%) and no difference between groups. There was no mortality in 30 or 90 days. Conclusion: Postoperative outcomes were similar for patients who underwent SG regardless of the assistant's level of training. Including residents in bariatric procedures is safe and does not affect patient safety. Encouraging residents to participate in complex MIS procedures is recommended as part of their training.

Permanent vs Absorbable Mesh for Ventral Hernia Repair in Contaminated Fields: Multicenter Propensity-Matched Analysis of 1-Year Outcomes Using the Abdominal Core Health Quality Collaborative Database.

BACKGROUND: Traditionally, the use of absorbable mesh in contaminated fields aimed to reduce postoperative morbidity at the expense of increased hernia recurrence. This dogma has recently been challenged in randomized trials that demonstrate the advantages of permanent mesh in this setting. Although these studies are of high quality, their reproducibility across institutions is limited. We sought to compare the outcomes between permanent and absorbable mesh in a multicentric cohort from the Abdominal Core Health Quality Collaborative. STUDY DESIGN: Patients who underwent elective ventral hernia repair in class II and III surgeries from January 2013 to December 2021 were identified within the Abdominal Core Health Quality Collaborative. Outcomes were compared among permanent (P), absorbable synthetic (AS), and biologic (B) mesh at 30 days and 1 year using a propensity score-matched analysis. RESULTS: A total of 2,484 patients were included: 73.4% P, 11.2% AS, and 15.4% B. Of these, 64% were clean-contaminated and 36% contaminated interventions. After propensity score-matched analysis, there was no significant difference between groups regarding surgical site occurrence (P 16%, AS 15%, B 21%, p = 0.13), surgical site infection (P 12%, AS 14%, B 12%, p = 0.64), and surgical site occurrence requiring procedural intervention at 30 days (P 12%, AS 15%, B 17%, p = 0.1). At 1 year, the recurrence rate was significantly lower among the permanent group (P 23%, AS 40%, B 32%, p = 0.029). CONCLUSIONS: In this multicentric cohort, permanent mesh has equivalent 30-day outcomes and lower rates of hernia recurrence at 1 year after hernia repair in contaminated fields.

Does the Weight Matter? Short-Term Outcomes of Lightweight Versus Heavyweight Three-Dimensional Anatomical Mesh in Minimally Invasive Inguinal Hernia Repair.

Background: The type of mesh used in inguinal hernia repairs remains controversial. There are limited data looking at specific mesh-related complications. The objective of this study is to assess postoperative 90-day outcomes in lightweight (LW) and heavyweight (HW) anatomical mesh in minimally invasive inguinal hernia repairs. Methods: A retrospective single-center database was queried for all adult minimally invasive inguinal hernia repairs with anatomical mesh from July 2016 to March 2021. Demographics and surgical outcomes were analyzed. Univariate analysis and multivariate logistic regression were performed. Results: Six hundred forty-seven minimally invasive inguinal hernia repairs were performed with 423 (65.3%) using HW and 224 (24.7%) using LW mesh. There was no difference in mean body mass index between the groups (26.9 ± 4.2 kg/m2 in the LW group and 27.1 ± 4.2 kg/m2 in the HW group; P = .69). There was no difference in type of mesh fixation used in either group, with tacker being the most common. There was no difference in postoperative emergency department (ED) visit (P = .625), readmission rates (P = .562), or postoperative complications between the two groups. Fifty patients presented with seroma within 90 days. There were five recurrences in each group and only one surgical site infection in the LW within 90 days. Multivariate logistic regression was performed, and predictors of seroma formation included age (odds ratio [OR] 1.02; confidence interval [CI] 1-1.04; P = .02) and hypertension (HTN) (OR 1.8; CI 1.03-3.4; P = .039). HW mesh was not associated with seroma formation (OR 1.04; CI 0.5-1.9; P = .895). Similarly, HW mesh was not associated with surgical site occurrences (SSO) (OR 1.04; CI 0.5-1.8; P = .872). HTN was associated with SSO (OR 1.74; CI 1-3.05; P = .048). Conclusion: Our study did not favor the use of LW or HW mesh when comparing postoperative complications or clinical outcomes. HW mesh was not associated with either seroma formation or SSO.