The current role of barbed sutures in fascial closure of ventral hernia repair: a multicenter study using the abdominal core health quality collaborative database.

BACKGROUND: Barbed sutures (BS) have been increasingly used in the last two decades across surgical disciplines but little is known about how widespread their adoption has been in ventral hernia repair (VHR). The aim of this study was to document the use of barbed sutures in VHR in a multicenter database with associated clinical and patient-reported outcomes. METHOD: Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent VHR with fascial closure from 2020 to 2022. A univariate analysis compared patients with BS against non-barbed sutures (NBS) across the preoperative, intraoperative, and postoperative timeframes including patient-reported outcomes concerning quality of life and pain scores. RESULTS: A total of 4054 patients that underwent ventral hernia repair with BS were compared with 6473 patients with non-barbed sutures (NBS). Overall, BS were used in 86.2% of minimally invasive ventral hernia repairs and about 92.2% of robotic surgery compared to only 9.6% of open procedures. Notable differences existed in patient selection, including a higher BMI (32 vs 30.5; p < 0.001), more incisional hernias (63.3% vs 51.1%; p < 0.001), wider hernias (4 cm vs 3 cm; p < 0.001), and higher ASA score (p < 0.001) in patients with BS. Outcomes in patients with BS included a shorter length of stay (mean days; 1.4 vs 2.4; p < 0.001), less SSI (1.5% vs 3.6%; p < 0.001), while having similar SSO (7.6% vs 7.3%; p = 0.657), readmission (3.0 vs 3.2; p = 0.691), and reoperation (1.5% vs 1.45%; p = 0.855), at a longer operative time (p < 0.001). Hernia-specific questionnaires for quality of life (HerQLes) and pain in patients with BS had a worse preoperative score that was later matched and favorable compared to NBS (p = 0.048). PRO concerning hernia recurrence suggest around 10% at two years of follow-up (p = 0.532). CONCLUSION: Use of barbed sutures in VHR is widespread and highly related to MIS. Outcomes from this multicenter database cannot be reported as superior but suggest that barbed sutures do not have a negative impact on outcomes.

Elective complex ventral hernia repair in contaminated fields: A propensity score-matched analysis of long-term quality of life and outcomes between different prostheses.

BACKGROUND: Randomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain. METHODS: The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II-IV) ventral hernia repair (2013-2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh. RESULTS: A total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53-70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12-25) and 13 cm (IQR 8-16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups. CONCLUSION: In the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.

Robotic preperitoneal extended totally extraperitoneal (R-PeTEP) technique description for ventral hernia repair: preliminary results.

PURPOSE: Transabdominal preperitoneal (TAPP) ventral hernia repair requires incising the peritoneum from within the abdominal cavity, developing a flap, and placing a reinforcing mesh after fascial closure from the preperitoneal space. We present a novel adaptation to this technique that allows placement of preperitoneal mesh without entering the abdominal cavity. The robotic totally extra- and preperitoneal (R-PeTEP) access for ventral hernia repair is best suited for small to moderate sized ventral hernias with concomitant diastasis recti. METHODS: Our study is a retrospective review of all patients who underwent R-PeTEP from December 2022 to November 2023. A comprehensive description of the surgical technique is included. Patient demographics, hernia characteristics, as well as clinical outcomes are described. RESULTS: A total of 25 patients underwent R-PeTEP for ventral hernia repair with diastasis recti plication. The median age was 55 years (IQR 43.5-63) and 92% (n = 23) were male. The median ASA score was 2 (IQR 1-2) and the median BMI was 30.4 (IQR 29.3-32.8) with 64% (n = 16) percent having a BMI ≥ 30. Median hernia width was 3 cm (IQR 3-4), with a median diastasis recti width of 4 cm (IQR 2.6-4) and length of 15 cm (IQR 11.8-16). The median operative time was 120 min (IQR 116-134). All repairs were reinforced with permanent mesh. Sixty-eight percent of the patients (n = 17) were discharged on the same day. With a median follow-up of 30 days (IQR 16-107), 8% (n = 2) seromas, 16% (n = 4) developed clinically insignificant hematomas, and one patient (4%) developed ileus that was managed conservatively. CONCLUSION: This study establishes the feasibility and safety of R-PeTEP, which provides direct access to the preperitoneal space, avoiding disruption to the posterior rectus sheath, possibly reducing neurovascular bundle injuries, and omitting entry to the abdominal cavity. R-PeTEP facilitates wide flap creation for prosthetic overlap and allows for posterior plication of diastasis recti with little to no mesh fixation with overall excellent preliminary clinical outcomes.

Research prioritization in hernia surgery: a modified Delphi ACHQC and VHOC expert consensus.

PURPOSE: Numerous clinical practice guidelines and consensus statements have been published in hernia surgery, however, there is still a need for high-quality evidence to address remaining unanswered questions. The aim of this study was to conduct research priority setting through a modified Delphi process to identify a list of top research priorities in hernia surgery. METHODS: A structured literature review of clinical practice guidelines was performed by the steering committee. Topics considered clinically significant, practical to study and lacking strong evidence were extracted and refined into a comprehensive list, then entered into a two-round Delphi survey for prioritization at the Abdominal Core Health Quality Collaborative (ACHQC) Quality Improvement Summit. In round 1, participants were instructed to select any topic that should be prioritized for future research. Topics were ranked according to the proportion of votes and the 25 highest-ranking topics were included in the second round. In round 2, participants were instructed to select only the top 10 topics for research prioritization. RESULTS: Eleven clinical practice guidelines were reviewed. Eighty-seven topics were extracted by the steering committee and submitted for prioritization. After the first round, 25 of the highest-ranking topics were determined and included in the second round. A final list of 11 research questions was identified. The hernia types with the most research interest were inguinal and epigastric/umbilical hernias. Other topics of high interest were the management of diastasis recti, primary versus mesh repairs and expectant management versus surgical repair. CONCLUSION: Our study provides a research agenda generated through expert consensus that may be used in the prioritization of the design and funding of clinical trials in hernia surgery.

Robotic-assisted endoscopic onlay repair (R-ENDOR) for concomitant ventral hernias and diastasis recti: initial results and surgical technique.

BACKGROUND: The surgical management of midline ventral hernias complicated by concomitant diastasis recti presents a significant clinical challenge. The Endoscopic Onlay Repair (ENDOR) offers a minimally invasive solution, effectively addressing both conditions. This study focuses on describing the adaptation of ENDOR to a robotic platform, termed R-ENDOR, aiming to report initial outcomes along with other established robotic surgical approaches. METHODS: This retrospective case series study included consecutive adult patients who underwent R-ENDOR approach from October 2018 to April 2023, performed by a single surgeon. A comprehensive description of the surgical technique is included. Patient demographics, operative, and hernia-specific characteristics, as well as clinical outcomes are described. RESULTS: A total of 15 patients undergoing R-ENDOR for ventral hernia repair with diastasis recti plication were included. The median age was 59 years (IQR 42-63), with 60% (n = 9) female patients. The majority (86%, n = 13) had an ASA score of ≤ 2, and the median BMI was 24 kg/m2, with 20% (n = 3) classified as obese. Median hernia size was 2 cm (IQR 2-2.25), with a median diastasis length of 19 cm (IQR 15-21.5) and width of 4 cm (IQR 3-6). The median operative time was 129 min (IQR 113-166). Most repairs (93%, n = 14) were reinforced with mesh, predominantly self-fixating (73.3%, n = 11). Eighty percent of patients (n = 12) were discharged on the same day, with a median follow-up of 153 days (IQR 55-309). Notable complications included clinically significant seromas in 20% of patients (n = 3), long-term hypoesthesia in 40% (n = 6), and readmission in one patient (6.6%) for surgical site infection (SSI) requiring IV antibiotic therapy. CONCLUSION: Midline ventral hernias associated to diastasis recti can be managed robotically by ENDOR with safe and consistent 90-day outcomes in a carefully selected group of patients.

Comparison of short-term outcomes following robotic ventral hernia repair in patients with obesity: a review of 9742 patients from the Abdominal Core Health Quality Collaborative database.

Despite the paucity of evidence on robotic ventral hernia repair (RVHR) in patients with obesity, the robotic platform is being used more frequently in hernia surgery. The impact of obesity on RVHR outcomes has not been thoroughly studied. Obesity is considered a major risk factor for the development of recurrent ventral hernias and postoperative complications; however, we hypothesize that patients undergoing robotic repairs will have similar complication profiles despite their body mass index (BMI). We performed a retrospective analysis of patients aged 18-90 years who underwent RVHR between 2013 and 2023 using data from the Abdominal Core Health Quality Collaborative registry. Preoperative, intraoperative, and postoperative characteristics were compared in non-obese and obese groups, determined using a univariate and logistic regression analysis to compare short-term outcomes. The registry identified 9742 patients; 3666 were non-obese; 6076 were classified as obese (BMI > 30 kg/m2). There was an increased odds of surgical site occurrence in patients with obesity, mostly seroma formation; however, obesity was not a significant factor for a complication requiring a procedural intervention after RVHR. In contrast, the hernia-specific quality-of-life scores significantly improved following surgery for all patients, with those with obesity having more substantial improvement from baseline. Obesity does increase the risk of certain complications following RVHR in a BMI-dependent fashion; however, the odds of requiring a procedural intervention are not significantly increased by BMI. Patients with obesity have a significant improvement in their quality of life, and RVHR should be carefully considered in this population.

Acute Leukemia Relapse after Hematopoietic Stem Cell Transplantation: The Good, the Bad, and the Ugly of Isolated Extramedullary Relapse in a Latin American Population.

Hematopoietic stem cell transplantation (HSCT) is an effective therapy for acute leukemia (AL). Relapse represents the main cause of mortality. Isolated extramedullary relapse (iEMR) is atypical and has been related to better outcomes. Here we describe the clinical characteristics and outcomes of AL relapse after HSCT in our study population and analyze the impacts of different types of relapse on survival outcomes. This retrospective, multicenter study included 124 patients age ≥15 years with AL who underwent HSCT between 2004 and 2019. At diagnosis, 66.1% of the patients had lymphocytic AL, 19.7% presented with high-risk features, and 18.5% had extramedullary disease (EMD). At HSCT, 83.1% of the patients were in complete remission (CR), and 44.8% had negative measurable residual disease (MRD). The vast majority of donors were related (96%), including 48.4% HLA-matched and 47.6% haploidentical. Myeloablative conditioning was provided to 80.6% of patients. The median overall survival (OS) was 15 months (95% confidence interval [CI] 9.9 to 20.1 months). Factors associated with improved OS were adolescent and young adult (AYA) patient (P = .035), first or second CR (P = .026), and chronic graft-versus-host disease (GVHD) (P < .001). Acute GVHD grade III-IV (P = .009) was associated with increased mortality. The median relapse-free survival was 13 months (95% CI, 7.17 to 18.8 months); early disease status (P = .017) and chronic GVHD (P < .001) had protective roles. Sixty-eight patients (55%) relapsed after HSCT, with a median time to relapse of 6 months (95% CI, 3.6 to 8.4 months). iEMR was reported in 16 patients (23.5%). The most commonly involved extramedullary sites were the central nervous system and skin. Compared to patients with bone marrow relapse, all patients with iEMR had a diagnosis of acute lymphoid leukemia (P = .008), and 93.8% belonged to the AYA group; regarding pre-HSCT characteristics, iEMR patients had higher rates of negative MRD (P = .06) and a history of EMD (P = .009). Seventy-seven percent of relapsed patients received additional treatment with curative intent. The median OS after relapse (OSr) was 4 months (95% CI, 2.6 to 5.4 months). Factors related to increased OSr included lymphoid phenotype (P = .03), iEMR (P = .0042), late relapse (≥6 months) (P = .014), receipt of systemic therapy including second HSCT (P < .001), and response to therapy (P < .001). Rates of relapse and iEMR were higher than those previously reported in other studies. Advanced disease, reduced-intensity conditioning, and a diminished graft-versus-leukemia effect were factors influencing these findings. At relapse, presenting with iEMR after 6 months and receiving intensive therapy with adequate response were associated with better outcomes. Our results strongly suggest that a personalized approach to treating patients with HSCT is needed to counterbalance specific adverse factors and can positively impact clinical outcomes.