Robotic-assisted laparoscopic inguinal hernia repair after previous transabdominal prostatectomy.

BACKGROUND: Transabdominal prostatectomy results in scarring of the retropubic space and this might complicate subsequent preperitoneal dissection and mesh placement during minimally invasive inguinal hernia repair. Therefore, it suggested that an open anterior technique should be used rather than a minimally invasive posterior technique in these patients. METHODS: In this single-center study, a retrospective analysis of a prospectively maintained database was performed. All patients undergoing inguinal hernia repair after previous transabdominal prostatectomy were included in this analysis, and the feasibility, safety, and short-term outcomes of open and robotic-assisted laparoscopic inguinal hernia repair were compared. RESULTS: From 907 inguinal hernia operations performed between March 2015 and March 2020, 45 patients met the inclusion criteria. As the number of patients treated with conventional laparoscopy was very low (n = 2), their data were excluded from statistical analysis. An open anterior repair with mesh (Lichtenstein) was performed in 21 patients and a robotic-assisted laparoscopic posterior transabdominal repair (rTAPP) in 22. Patient characteristics between groups were comparable. A transurethral urinary catheter was placed during surgery in 17 patients, most often in the laparoscopic cases (15/22, 68.2%). In the rTAPP group, a higher proportion of patients was treated for a bilateral inguinal hernia (50%, vs 19% in the Lichtenstein group). There were no intraoperative complications and no conversions from laparoscopy to open surgery. No statistically significant differences between both groups were observed in the outcome parameters. At 4 weeks follow-up, more patients who underwent rTAPP had an asymptomatic seroma (22.7% vs 5% in the Lichtenstein group) and two patients were treated postoperatively for a urinary tract infection (4.7%). CONCLUSION: A robotic-assisted laparoscopic approach to inguinal hernia after previous transabdominal prostatectomy seems safe and feasible and might offer specific advantages in the treatment of bilateral inguinal hernia repairs.

Parastomal hernias after cystectomy and ileal conduit urinary diversion: surgical treatment and the use of prophylactic mesh: a systematic review.

BACKGROUND: Parastomal hernia after ileal conduit urinary diversion is an underestimated and undertreated clinical entity, which heavily impairs patients' quality of life due to symptoms of pain, leakage, application or skin problems. As for all gastrointestinal stomata the best surgical repair technique has yet to be determined. Thereby, surgery for ileal conduit parastomal hernias poses some specific perioperative challenges. This review aims to give an overview of current evidence on the surgical treatment of parastomal hernia after cystectomy and ileal conduit urinary diversion, and on the use of prophylactic mesh at index surgery in its prevention. METHODS: A systematic review was performed according to PRISMA-guidelines. The electronic databases Embase, PubMed, Cochrane Library, and Web of Science were searched. Studies were included if they presented postoperative outcomes of patients undergoing surgical treatment of parastomal hernia at the ileal conduit site, irrespective of the technique used. A search was performed to identify additional studies on prophylactic mesh in the prevention of ileal conduit parastomal hernia, that were not identified by the initial search. RESULTS: Eight retrospective case-series were included for analysis, reporting different surgical techniques. If reported, highest complication rate was 45%. Recurrence rates varied highly, ranging from 0 to 80%. Notably, lower recurrence rates were reported in studies with shorter follow-up. Overall, available data suggest significant morbidity after the surgical treatment of ileal conduit parastomal hernias. Data from five conference abstracts on the matter were retrieved, and systematically reported. Regarding prophylactic mesh in the prevention of ileal conduit parastomal hernia, 5 communications were identified. All of them used keyhole mesh in a retromuscular position, and reported on favorable results in the mesh group without an increase in mesh-related complications. CONCLUSION: Data on the surgical treatment of ileal conduit parastomal hernias and the use of prophylactic mesh in its prevention is scarce. Given the specific perioperative challenges and the paucity of reported results, more high-quality evidence is needed to determine the optimal treatment of this specific surgical problem. Initial results on the use of prophylactic mesh in the prevention of ileal conduit parastomal hernias seem promising.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair.

BACKGROUND: Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. METHODS: A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. RESULTS: Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. CONCLUSION: Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

ANTECEDENTES: La nomenclatura de la inserción de una malla para la reparación de una hernia incisional ventral (ventral hernia, VH) es inconsistente y confusa. En la literatura indexada se usan varios términos, tales como 'inlay', 'sublay', y 'underlay' que pueden referirse a los mismos planos anatómicos. Este hecho frustra las comparaciones de técnicas quirúrgicas e invalida los metaanálisis que comparan resultados quirúrgicos en función del plano de inserción de la malla. En consecuencia, el objetivo de este estudio fue establecer una clasificación internacional de los planos de la pared abdominal (International Classification of Abdominal Wall Planes, ICAP). MÉTODOS: Se realizó un estudio Delphi, en el que participaron 20 cirujanos de pared abdominal reconocidos internacionalmente. Se identificaron diferentes términos que describían los planos de la pared abdominal anterior mediante la revisión de la literatura y el consenso de expertos. La lista inicial incluía 59 términos posibles. Los panelistas completaron un cuestionario que sugería una lista de opciones para los planos individuales de la pared abdominal. El consenso sobre un término fue predefinido cuando dicho término había sido seleccionado por ≥ 80% de panelistas. Se eliminaron los términos con una puntuación < 20%. RESULTADOS: La votación comenzó en agosto de 2018 y se completó en enero de 2019. Durante la Ronda 1, 43 (73%) términos fueron seleccionados por < 20% de los panelistas y se sugirieron 37 términos nuevos, dejando 53 términos para la Ronda 2. Cuatro planos alcanzaron un consenso en la Ronda 2 con los términos 'onlay', 'inlay', 'pre-peritoneal' e 'intra-peritoneal'. Treinta y cinco (66%) términos fueron seleccionados por < 20% de los panelistas y fueron eliminados. Después de la Ronda 3, se logró un consenso para 'anterectus' (ante-recto), 'interoblique' (inter-oblicuo), 'retrooblique' (retro-oblicuo) y 'retromuscular'. Se alcanzó un consenso por defecto para los planos 'retrorectus' (retro-recto) y 'transversalis fascial' (fascial transverso). CONCLUSIÓN: La ICAP ha sido desarrollada por el consenso de 20 cirujanos reconocidos internacionalmente. Su implementación debería mejorar la comunicación y la comparación entre cirujanos y estudios de investigación.

Open ventral hernia repair with a composite ventral patch - final results of a multicenter prospective study.

BACKGROUND: This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex™ Composite Ventral Patch (PCO-VP). METHODS: A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed. RESULTS: One hundred twenty-six subjects (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8 cm (0.4-4.0) were treated with PCO-VP. One hundred subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0-6.3%) within 24 months. Median Numeric Rating Scale pain scores improved from 2 [0-10] at baseline to 0 [0-3] at 1 month (P < 0.001) and remained low at 24 months 0 [0-6] (P < 0.001). 99% (102/103) of the patients were satisfied with their repair at 24 months postoperative. CONCLUSIONS: The use of PCO-VP to repair primary umbilical and epigastric defects yielded a low recurrence rate, low postoperative and chronic pain, and high satisfaction ratings, confirming that PCO-VP is effective for small ventral hernia repair in the two-year term after implantation. TRIAL REGISTRATION: The study was registered publically at clinicaltrials.gov ( NCT01848184 registered May 7, 2013).

Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review.

BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection. METHODS: A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed. RESULTS: A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86). CONCLUSIONS: There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.

[Laparotomy closure - do we know how?(Guideline of the European Hernia Society)]. / Uzáver laparotomie - víme jak?(Doporucení Evropské kýlní spolecnosti).

The recurrence rate of surgical treatment of incisional hernia is high. The material and surgical technique used to close the abdominal wall following every surgery contribute as important risk factors in incisional hernia formation. However, by optimising abdominal wall closure, many patients can be spared from developing this type of complication. The European Hernia Society has established a Guidelines Development Group with a goal to research the literature and write a series of recommendations of how to close the abdomen and minimize the risk of incisional hernia in accordance with the principles of evidence-based medicine. To decrease the incidence of incisional hernias, the following is recommended: To utilise a non-midline approach to a laparotomy whenever possible. To perform a continuous suturing technique using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique. To perform the small bites technique with a suture to wound length (SL/WL) ratio at least 4/1. Not to close the peritoneum separately. To avoid rapidly resorbable materials. To consider using a prophylactic mesh in high-risk patients. To use the smallest trocar size adequate for the procedure and closing the fascial defect if trocars larger or equal to 10 mm are used in laparoscopic surgery. Key words: incisional hernia laparotomy laparotomy closure suturing material.

A belgian multicenter prospective observational cohort study shows safe and efficient use of a composite mesh with incorporated oxidized regenerated cellulose in laparoscopic ventral hernia repair.

BACKGROUND: A variety of anti-adhesive composite mesh products have become available to use inside the peritoneal cavity. However, reimbursement of these meshes by the Belgian Governemental Health Agency (RIZIV/INAMI) can only be obtained after conducting a prospective study with at least one year of clinical follow-up. This -Belgian multicentric cohort study evaluated the experience with the use of Proceed®-mesh in laparoscopic ventral hernia repair. METHODS: During a 25 month period 210 adult patients underwent a laparoscopic primary or incisional hernia repair using an intra-abdominal placement of Proceed®-mesh. According to RIZIV/INAMI criteria recurrence rate after 1 year was the primary objective, while postoperative morbidity, including seroma formation, wound and mesh infections, quality of life and recurrences after 2 years were evaluated as secondary endpoints (NCT00572962). RESULTS: In total 97 primary ventral and 103 incisional hernias were repaired, of which 28 (13%) were recurrent. There were no conversions to open repair, no enterotomies, no mesh infections and no mortality. One year cumulative follow-up showed 10 recurrences (n = 192, 5.2%) and chronic discomfort or pain in 4.7% of the patients. Quality of life could not be analyzed due to incomplete data set. CONCLUSIONS: More than 5 years after introduction of this mesh to the market, this prospective multicentric study documents a favorable experience with the Proceed mesh in laparoscopic ventral hernia repair. However, it remains to be discussed whether reimbursement of these meshes in Belgium should be limited to the current strict criteria and therefore can only be obtained after at least 3-4 years of clinical data gathering and necessary follow-up.

The laparoscopic modified Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study.

BACKGROUND: Parastomal hernia is a frequent complication of intestinal stomata. Mesh repair gives the best results, with the mesh inserted via laparotomy or laparoscopically. It was the aim of this retrospective multicenter study to determine the early and late results of the laparoscopically performed, modified Sugarbaker technique with ePTFE mesh. METHODS: From 2005 to 2010, a total of 61 consecutive patients (mean age = 61 years), with a symptomatic parastomal hernia, underwent laparoscopic repair using the modified Sugarbaker technique with ePTFE mesh. Fifty-five patients had a colostomy, 4 patients an ileostomy, and 2 a urostomy according to Bricker. The records of the patients were reviewed with respect to patient characteristics, postoperative morbidity, and mortality. All patients underwent physical examination after a follow-up of at least 1 year to detect a recurrent hernia. Morbidity rate was 19 % and included wound infection (n = 1), ileus (n = 2), trocar site bleeding (n = 2), reintervention (n = 2), and pneumonia (n = 1). One patient died in the postoperative period due to metastasis of lung carcinoma that caused bowel obstruction. Concomitant incisional hernias were detected in 25 of 61 patients (41 %) and could be repaired at the same time in all cases. A recurrent hernia was found in three patients at physical examination, and in one patient an asymptomatic recurrence was found on a CT scan. The overall recurrence rate was 6.6 % after a mean follow-up of 26 months. CONCLUSION: The laparoscopic Sugarbaker technique is a safe procedure for repairing parastomal hernias. In our study, the overall morbidity was 19 % and the recurrence rate was 6.6 % after a mean follow-up of 26 months. Moreover, the laparoscopic approach revealed concomitant hernias in 41 % of the patients, which could be repaired successfully at the same time.

The principles of abdominal wound closure.

BACKGROUND: Incisional hernia (IH) is a common complication of abdominal surgery. Its incidence has been reported as high as 39.9%. Many factors influence IH rates. Of these, surgical technique is the only factor directly controlled by the surgeon. There is much evidence in the literature on the optimal midline laparotomy closure technique. Despite the high level of evidence, this optimal closure technique has not met wide acceptance in the surgical community. In preparation of a clinical trial, the PRINCIPLES trial, a literature review was conducted to find the best evidence based technique for abdominal wall closure after midline laparotomy. METHODS: An Embase search was performed. Articles describing closure of the fascia after midline laparotomy by different suture techniques and/or suture materials were selected. RESULTS: Fifteen studies were identified, including five meta-analyses. Analysis of the literature showed significant lower IH rates with single layer closure, using a continuous technique with slowly absorbable suture material. No significant difference in IH incidence was found comparing slowly absorbable and non absorbable sutures. Furthermore, a suture length to wound length ratio of four or more and short stitch length significantly decreased IH rates. CONCLUSIONS: Careful analysis of the literature indicates that an evidenced based optimal midline laparotomy closure technique can be identified. This technique involves single layer closure with a running suture, using a slowly absorbable suture with a suture length to wound length ratio of four or more and a short stitch length. We adopt this technique as the PRINCIPLES technique.

Economic assessment of starting robot-assisted laparoscopic inguinal hernia repair in a single-centre retrospective comparative study: the EASTER study.

BACKGROUND: There has been a rapid adoption of robot-assisted laparoscopic inguinal hernia repair in the USA, despite a lack of proven clinical advantage and higher material cost. No studies have been published regarding the cost and outcome of robotic inguinal hernia surgery in a European Union setting. METHODS: A retrospective comparative study was performed on the early outcome and costs related to laparoscopic inguinal hernia repair, with either conventional or robot-assisted surgery. RESULTS: The study analysed 676 patients undergoing laparoscopic inguinal hernia repair (272 conventional and 404 robotic repairs). Conventional laparoscopic and robotic repair groups were comparable in terms of duration of surgery (57.6 versus 56.2 min respectively; P = 0.224), intraoperative complication rate (1.1 versus 1.2 per cent; P = 0.990), in-hospital complication rate (4.4 versus 4.5 per cent; P = 0.230) and readmission rate (3.3 versus 1.2 per cent; P = 0.095). There was a significant difference in hospital stay in favour of the robotic approach (P = 0.014), with more patients treated on an outpatient basis in the robotic group (59.2 per cent versus 70.0 per cent for conventional repair). At 4-week follow-up, equal numbers of seromas or haematomas were recorded in the conventional laparoscopic and robotic groups (13.3 versus 15.7 per cent respectively; P = 0.431), but significantly more umbilical wound infections were seen in the conventional group (3.0 per cent versus 0 per cent in the robotic group; P = 0.001). Robotic inguinal hernia repair was significantly more expensive overall, with a mean cost of €2612 versus €1963 for the conventional laparoscopic approach (mean difference €649; P < 0.001). CONCLUSION: Robot-assisted laparoscopic inguinal hernia repair was significantly more expensive than conventional laparoscopy. More patients were treated as outpatients in the robotic group. Postoperative complications were infrequent and mild.

A systematic review of outcome reporting in incisional hernia surgery.

BACKGROUND: The incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies. METHODS: Literature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included. RESULTS: In total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used. CONCLUSIONS: This review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis.

BACKGROUND: Incisional hernia is a frequent complication after abdominal surgery. The aim of this study was to assess the efficacy of prophylactic mesh reinforcement (PMR) after midline laparotomy in reducing the incidence of incisional hernia. METHODS: A meta-analysis was conducted following PRISMA guidelines. The primary outcome was the incidence of incisional hernia after follow-up of at least 12 months. Secondary outcomes were postoperative complications. Only RCTs were included. A random-effects model was used for the meta-analysis, and trial sequential analysis was conducted. RESULTS: Twelve RCTs were included, comprising 1815 patients. The incidence of incisional hernia was significantly lower after PMR compared with sutured closure (risk ratio (RR) 0·35, 95 per cent c.i. 0·21 to 0·57; P < 0·001). Both onlay (RR 0·26, 0·11 to 0·67; P = 0·005) and retromuscular (RR 0·28, 0·10 to 0·82; P = 0·02) PMR led to a significant reduction in the rate of incisional hernia. The occurrence of seroma was higher in patients who had onlay PMR (RR 2·23, 1·10 to 4·52; P = 0·03). PMR did not result in an increased rate of surgical-site infection. CONCLUSION: PMR of a midline laparotomy using an onlay or retromuscular technique leads to a significant reduction in the rate of incisional hernia in high-risk patients. Individual risk factors should be taken into account to select patients who will benefit most. [Correction added on 19 February 2020, after first online publication: J. García Alamino has been amended to J. M. Garcia-Alamino].

ANTECEDENTES: La eventración (hernia incisional) es una complicación frecuente de la cirugía abdominal. El objetivo es evaluar la eficacia de la inserción de una malla profiláctica de refuerzo (prophylactic mesh reinforcement, PMR) después de la laparotomía media para reducir la incidencia de eventración. MÉTODOS: Se realizó un metaanálisis siguiendo las recomendaciones PRISMA. La variable principal fue la incidencia de eventración después de un seguimiento mínimo de 12 meses. Las variables secundarias fueron las complicaciones postoperatorias. Solo se incluyeron ensayos controlados aleatorizados. Se utilizó un modelo de efectos aleatorios para el metaanálisis y se realizó un análisis secuencial de los ensayos. RESULTADOS: Se incluyeron 12 ensayos aleatorizados y controlados con 1.815 pacientes. La incidencia de eventración fue significativamente menor después de la PMR en comparación con el cierre simple (riesgo relativo, RR 0,35; i.c. del 95%: 0,21-0,57, P < 0,0001). Hubo una reducción significativa de la tasa de eventración tanto si la PMR se colocó en posición supra-aponeurótica (RR 0,26; i.c. del 95% 0,11-0,67, P = 0,005) como retromuscular (RR 0,28; i.c. del 95% 0,0-0,82, P = 0,02). La aparición de seromas fue mayor en los pacientes con RPM supra-aponeurótica (RR 2,23; i.c. del 95% 1,10-4,52, P = 0,03). La PMR no conllevó una mayor tasa de infecciones de la herida quirúrgica. CONCLUSIÓN: Una PMR en una laparotomía de la línea media, tanto en posición supra-aponeurótica como retromuscular, reduce de forma significativa el desarrollo de eventraciones en pacientes de alto riesgo. Se deben considerar los factores de riesgo individuales para seleccionar a los pacientes que más puedan beneficiarse.

Correction to: European Hernia Society (EHS) guidance for the management of adult patients with a hernia during the COVID­19 pandemic.

The originally published article: The surname and given name of authors, M. Pawlak and A.C. de Beaux has been incorrectly published.

Concomitant cardiac surgery and pulmonary resection.

BACKGROUND: Surgical management of concomitant pulmonary and cardiac disease remains controversial. There is no consensus on the use of a one- or two-staged procedure, the timing of heparinization and the utilisation of cardio-pulmonary bypass. METHODS: We performed a retrospective review of 27 patients who underwent pulmonary and cardiac surgery, from 2000 to 2008, in two institutions. We focused on early postoperative morbidity and mortality. RESULTS: 24 men and 3 women, with a mean age of 68 years, were treated. Cardiac procedures consisted of coronary artery bypass grafting (n = 22), heart valve surgery (n = 3) or a combination of both (n = 2). Pulmonary resection included segmental resection (n = 1), lobectomy (n = 21), bilobectomy (n = 2) and pneumonectomy (n = 3). Histology of the pulmonary lesion was squamous cell carcinoma in 14 patients (52%), adenocarcinoma in 10 (37%), large cell neuroendocrine tumour in 1 (3%) and typical carcinoid in 1 (3%). The stage of the pulmonary malignancy was IA in 8 patients (31%), stage IB in 11 (42%), stage IIB in 5 (19%) and stage IIIB in 2 (8%). A benign lesion was found in 1 patient (3%). There was no in-hospital mortality. Postoperative complications occurred in 16 patients (59%) consisting of supraventricular arrhythmias in 11 (41%), pneumonia in 8 (30%), atelectasis in 6 (22%), ventricular arrhythmias in 2 (7%), pneumothorax in 1 (3%), pleural effusion in 1 (3%), and renal insufficiency in 1 patient (3%). Revision for bleeding was necessary in 3 patients (11%). The mean follow-up was 30,7 months with a median survival for all patients of 46 months. CONCLUSIONS: Simultaneous procedures for cardiac disease and pulmonary lesions can be performed without life-threatening morbidity and no in-hospital mortality.

Robot-assisted abdominal wall surgery: a systematic review of the literature and meta-analysis.

PURPOSE: The number of robot-assisted hernia repairs is increasing, but the potential benefits have not been well described. The aim of this study was to evaluate the available literature reporting on outcomes after robot-assisted hernia repairs. METHODS: This is a qualitative review and meta-analysis of papers evaluating short-term outcomes after inguinal or ventral robot-assisted hernia repair compared with either open or laparoscopic approach. The primary outcome was postoperative complications and secondary outcomes were duration of surgery, postoperative length of stay and financial costs. RESULTS: Fifteen studies were included. Postoperative complications were significantly decreased after robot-assisted inguinal hernia repair compared with open repair. There were no differences in complications between robot-assisted and laparoscopic inguinal hernia repair. For ventral hernia repair, sutured closure of the defect, retromuscular mesh placement and transversus abdominis release is feasible when using the robot. Length of stay was decreased by a mean of 3 days for robot-assisted repairs compared with open approach. There were no differences in postoperative complications and the operative time was significantly longer for robot-assisted ventral hernia repair compared with laparoscopic or open approach. CONCLUSIONS: For ventral hernias that would normally require an open procedure, a robot-assisted repair may be a good option, as the use of a minimally invasive approach for these procedures decreases length of stay significantly. For inguinal hernias, the benefit of the robot is questionable. Randomized controlled trials and prospective studies are needed.

IPOM: history of an acronym.

IPOM has become a common term used by hernia surgeons. It refers to the treatment of a ventral hernia using an intraperitoneal placed mesh and most consider it an acronym for Intra-Peritoneal Onlay Mesh. Since intraperitoneal placement of mesh has fallen out of favor with some hernia surgeons and key-opinion-leaders recently, this might be the correct time to write down and preserve the history of this intriguing acronym.

Robotic transabdominal retromuscular umbilical prosthetic hernia repair (TARUP): observational study on the operative time during the learning curve.

PURPOSE: The use of extraperitoneal mesh in place of intra-peritoneal mesh is gaining popularity in laparoscopic ventral hernia repair. We have adopted a robotic assisted laparoscopic technique using a lateral single-dock robotic access with retromuscular mesh placement after opening the ipsilateral posterior rectus fascia. In this study, we wanted to evaluate the changes in operative times during the initial experience with this novel technique. METHODS: The initial consecutive patients undergoing robotic assisted transabdominal retromuscular umbilical prosthetic repair (r-TARUP) using a 15 × 15 cm self-fixating mesh were prospectively entered in the study and the operative times during the separate steps of the surgical procedure were recorded. Complications were reported up to 4 week post operatively and quality of life was assessed using the EuraHS-QoL score. RESULTS: Over a 5 month inclusion period, 41 patients with either a primary (n = 34) or a trocar site hernia (n = 7) at the umbilicus were identified. All hernias had a mean diameter of less than 4 cm. The total OR time decreased significantly during the learning curve (tertile 1: 126 min versus tertile 3: 102 min; p = 0.002) due to a decrease in the skin-to-skin operating time (tertile 1: 81 min versus tertile 3:61 min; p = 0.002). The decrease in the retromuscular dissection time was the most significant of all the steps that comprised the console time (p = 0.004). The non-surgical time did not decrease (p = 0.15). The operation was performed on an outpatient basis in 68% of patients and with a one-night-stay in 29%. No complications related to the introduction of the robotic technique for this approach were observed and the early outcome is promising, with favorable quality-of-life evaluation at 4 weeks. CONCLUSIONS: The decrease in operative time during the adoption of r-TARUP was mainly related to the improved efficiency in the dissection phase of the procedure. The technique is reproducible and safe and the operative time compares favorably to published operative times for laparoscopic and open retromuscular umbilical hernia repair.

Comparing different modalities for the diagnosis of incisional hernia: a systematic review.

PURPOSE: Incisional hernia (IH) is the most frequent complication after abdominal surgery. The diagnostic modality, observer, definition, and diagnostic protocol used for the diagnosis of IH potentially influence the reported prevalence. The objective of this systematic review is to evaluate the diagnostic accuracy of different modalities used to identify IH. METHODS: Embase, MEDLINE OvidSP, Web of Science, Google Scholar, and Cochrane databases were searched to identify studies diagnosing IH. Studies comparing the IH detection rate of two different diagnostic modalities or inter-observer variability of one modality were included. Quality assessment of studies was done by Cochrane Collaboration's tool. Article selection and data collection were performed independently by two researchers. PROSPERO registration: CRD42017062307. RESULTS: Fifteen studies representing a total of 2986 patients were included. Inter-observer variation for CT-scan ranged from 11.2 to 69% (n = 678). Disagreement between ultrasound and CT-scan ranged between 6.6 and 17% (n = 221). Ten studies compared physical examination to CT-scan or ultrasound. Disagreement between physical examination and imaging ranged between 7.6 and 39% (n = 1602). Between 15 and 58% of IHs were solely detected by imaging (n = 483). Relative increase in IH prevalence for imaging compared to physical examination ranged from 0.92 to 2.4 (n = 1922). CONCLUSIONS: Ultrasound or CT-scan will result in substantial additional IH diagnosis. Lack of consensus regarding the definition of IH might contribute to the disagreement rates. Both the observer and diagnostic modality used could be additional factors explaining variability in IH prevalence and should be reported in IH research.