How Appropriate Are Recommendations of Online Chat-Based Artificial Intelligence (ChatGPT) to Common Questions on Ventral Hernia Repair?

ChatGPT is a conversational AI model developed by OpenAI to generate human-like text based on the input it receives. ChatGPT has become increasingly popular, and the general public may use this tool to ask questions about different medical conditions. There is a lack of data to demonstrate ChatGPT is able to provide reliable information on medical conditions. The aim of our study is to assess the accuracy and appropriateness of ChatGPT answers to questions on ventral hernia management.

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.

Appropriateness of Online Chat-Based Artificial Intelligence (ChatGPT) Answers to Common Questions on Inguinal Hernia Repair.

ChatGPT is a conversational AI model developed by OpenAI designed to generate human-like text based on the input it receives. ChatGPT has become increasingly popular, and the general public may use this tool to ask questions about different medical conditions. There is a lack of data showing if ChatGPT is able to provide reliable information on medical conditions to the general public. The aim of our study is to assess the accuracy and appropriateness of ChatGPT answers to questions on inguinal hernia management.

Transplant Ureter Inguinal Herniation Treated by Robotic Inguinal Hernia Repair.

Introduction: We report the case of a transplanted ureter obstructed by an inguinal herniation treated by a robotic-assisted approach. Case Report: This is a case of a 63-year-old male who had a kidney transplant with a graft on the left pelvis in September 2014, and presented to the clinic for evaluation of bilateral inguinal hernia. On physical examination he had bilateral palpable inguinal hernias, with the right one larger and only partially reducible. Computed tomography scan showed portion of urinary bladder and transplant ureter in the left inguinal hernia and mild hydroureteronephrosis in the transplanted kidney. Patient underwent catheterization of the transplant ureter where indocyanine green was injected for proper transplant ureter identification with the Firefly filter and robotic assisted hernia repair. Surgery was uneventful and patient was discharged home the same day with no further complications. Conclusion: The robotic approach using the Firefly filter was shown to be safe during the dissection to avoid injury to the transplant ureter.

Slowly absorbable mesh in sublay ventral hernia repair in contaminated fields.

BACKGROUND: In the past years, there has been increasing evidence that supports the use of permanent mesh in contaminated wounds. Given this increased evidence, the indications to opt for slowly absorbable "biosynthetic" prostheses have been questioned. To address this, we compared the outcomes of slowly absorbable mesh in contaminated cases in a well-matched multicentric cohort. METHODS: The Abdominal Core Health Quality Collaborative (ACHQC) database was queried for patients undergoing elective ventral hernia repair in Centers for Disease Control (CDC)-III operations (2013-2022). We compared demographics, hernia characteristics, and postoperative outcomes among types of mesh. We used propensity score matching to adjust for sex, diabetes, body mass index, smoking status, and operative time between mesh groups. Patients within other CDC classes and those with mesh positioned elsewhere than retro-rectus/preperitoneal space were excluded. RESULTS: A total of 760 patients were included in the analysis. Slowly absorbable synthetic mesh (SA) was utilized in only 7% of the cases, while permanent (P) and biologic (B) mesh in 77% and 16%, respectively. After matching, 255 patients were studied. There was no difference in surgical site occurrence (8% SA, 16% P, 10% B, p = 0.27), surgical site infection (20% SA, 17% P, 12% B p = 0.54), surgical site occurrence requiring intervention (18% SA, 13% P, 14% B p = 0.72), readmission (12% SA, 14% P, 12% B, p = 0.90), or reoperation (8% SA, 2% P, 4% B, p = 0.14) at 30 days. In patients with 1-year follow-up, there was no difference in recurrence among groups (20% SA, 26% P, 24% B p = 0.90). CONCLUSION: Based on our findings, SA has comparable outcomes to other types of mesh, particularly when an optimal retro-rectus repair is performed.

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.

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.

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.

Robotic approach in complex ventral hernias: anterior component separation technique.

Open onlay ventral hernia repair is still one of the most-used surgical techniques for the repair of hernias worldwide. The robotic anterior component separation technique uses the surgeon's usual anatomical expertise on onlay mesh placement with the manipulation and advantages of minimally invasive surgery. It maintains the precepts of reestablishment the midline integrity and insertion of mesh in the preaponeurotic space, without contact with the viscera. The use of this technique is simple and quite reproducible if you compare it with other techniques. Also, the time spent in surgery does not last long.

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.

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.

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.

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.

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.

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.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies.

BACKGROUND: Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. METHODS: A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. RESULTS: Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. CONCLUSION: These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

An incisional hernia results from a weakness of the abdominal wall muscles that allows fat from the inside or organs to bulge out. These hernias are quite common after abdominal surgery at the site of a previous incision. There is research that discusses different ways to close an incision and this may relate to the chance of hernia formation. The aim of this study was to review the latest research and to provide a guide for surgeons on how best to close incisions to decrease hernia rates. When possible, surgery through small incisions may decrease the risk of hernia formation. If small incisions are used, it may be better if they are placed away from areas that are already weak (such as the belly button). If the incision is larger than 1 cm, it should be closed with a deep muscle-fascia suture in addition to skin sutures. If there is a large incision in the middle of the abdomen, the muscle should be sutured using small stitches that are close together and a slowly absorbable suture should be used. For patients who are at higher risk of developing hernias, when closing the incision, the muscle layer can be strengthened by using a piece of (synthetic) mesh. There is no good research available on recovery after surgery and no clear guides on activity level or whether a binder will help prevent hernia formation.

Lateral hernia secondary to colorectal submucosal resection repaired by robotic-assisted approach: Case report.

INTRODUCTION AND IMPORTANCE: Lateral abdominal wall defects are a rare event and commonly result from iatrogenic causes and trauma. We report the first known case of flank hernia after endoscopic submucosal resection of a colonic polyp complicated by colonic perforation. CASE PRESENTATION: This is a case of a 50-year-old male who underwent endoscopic colonic resection complicated by perforation of the colon. Eight months later, he presented with an enlarging, asymptomatic left flank bulge. CT showed a large flank hernia which was successfully repaired using a robotic transabdominal preperitoneal (TAP) approach. CLINICAL DISCUSSION: The hypothesis is that the endoscopic resection with colonic perforation caused an iatrogenic injury to the abdominal wall creating a lateral abdominal hernia. Injury to abdominal wall musculature may take months to develop into a clinically apparent hernia. Flank hernias can be successfully repaired using a robotic minimally invasive approach. CONCLUSION: Flank bulge and hernias must be included or at least be considered as consequence of a potential complication from endoscopic colonic perforation. Surgeons and endoscopists must be aware of this potential complication and its latent presentation. This case stresses the importance of long-term outcomes monitoring, particularly with innovative procedures.

Robotic Intracorporeal Rectus Aponeuroplasty: Early Experience of a New Surgical Technique for Ventral Hernia Repair.

Introduction: The laparoscopic intracorporeal rectus aponeuroplasty (LIRA) was developed as an alternative for minimally invasive ventral hernia repair. This technique allows the closure of the defect and restoration of the midline without tension by plication of both aponeurosis of the abdominal rectus muscles combined with a minimally invasive intraperitoneal underlay mesh repair. The objective of this study is to report our early experience with the Robotic-LIRA (R-LIRA) technique and its safety and short-term efficacy. Methods: We performed a retrospective analysis of patients undergoing R-LIRA repair for ventral hernias from March 2019 to April 2022. Results: Eight patients underwent R-LIRA from March 2019 to April 2022. Median age was 47 years (interquartile range [IQR] 34.5-62.8). Median body mass index was 34.2 kg/m2 (IQR 29.9-35.2). Four patients (50%) had a primary ventral hernia being one M2, two M3, and one M2/M3. There were three incisional hernias, being one recurrent, 6 patients (75%) had associated diastasis of the rectus muscle and 1 patient presented pure diastasis. The median hernia width was 4 cm (IQR 2-6), and the median defect area was 16 cm2 (IQR 4-42). The median mesh area was 290 cm2 (IQR 211.2-300). In all cases, a barbed suture was also used for mesh fixation, and tackers were added in 4 cases. The median operative time was 172 minutes (IQR 139.8-293.3). The median length of stay was 0.5 days (IQR 0-1.8), and the median follow-up was 20 days (IQR 16-46). Conclusion: The R-LIRA has been shown to be safe and feasible for ventral and incisional hernia repairs with or without Diastasis of the Rectus Abdominis Muscle in the short term.

VERSATILITY OF POLY-4-HYDROXYBUTYRATE (PHASIX™) MESH IN ABDOMINAL WALL SURGERY.

BACKGROUND: Poly-4-hydroxybutyrate (P4HB) is a naturally occurring polymer derived from transgenic E. coli bacteria with the longest degradation rate when compared to other available products. This polymer has been manufactured as a biosynthetic mesh to be used as reinforcement when repairing a variety of abdominal wall defects. OBJECTIVE: We aim to describe our center initial experience with this mesh and discuss the possible indications that may benefit from the use of P4HB mesh. METHODS: This is a descriptive retrospective study of patients who underwent abdominal wall repair with a P4HB mesh from October 2018 to December 2020 in a single, large volume, academic center. RESULTS: A total of 51 patients (mean age 54.4 years, range 12-89) underwent abdominal wall reconstruction with a P4HB mesh between October 2018 and December 2020. The mean BMI was 30.5 (range 17.2-50.6). Twenty-three (45%) patients had a prior hernia repair at the site. We grouped patients into six different indications for the use of P4HB mesh in our cohort: clean-contaminated, contaminated or infected field (57%), patient refusal for permanent meshes (14%), those with high risk for post-operative infection (12%), visceral protection of second mesh (10%), recurrence with related chronic pain from mesh (6%), and children (2%). Median follow-up was 105 days (range 8-648). Two patients had hernia recurrence (4%) and 8 (16%) patients developed seroma. CONCLUSION: P4HB mesh is a safe and a viable alternative for complex hernias and high-risk patients with a low complication rate in the short-term.

Hernia Defect Closure With Barbed Suture: An Assessment of Patient-reported Outcomes in Extraperitoneal Robotic Ventral Hernia Repair.

BACKGROUND: Primary closure of a fascial defect during ventral hernia repair is associated with lower rates of recurrence and better patient satisfaction compared with bridging repairs. Robotic surgery offers enhanced ability to close these defects and this has likely been aided by the use of barbed suture. The goal of this study was to evaluate the perioperative safety and the long-term outcomes for the use of barbed suture for the primary closure of hernia defects during robotic ventral hernia repair (rVHR) with mesh. METHODS: This is a retrospective study of adult patients who underwent rVHR with the use of a barbed suture for fascial defect closure from August 2018 to August 2020 in an academic center. All the patients included were queried by phone to complete a quality of life assessment to assess patient-reported outcomes (PROs). Subjective sense of a bulge and pain at the previous hernia site has been shown to correlate with hernia recurrence. These questions were used in conjunction with a Hernia-related Quality of Life Survey (HerQles) score to assess a patient's quality of life. RESULTS: A total of 81 patients with 102 hernias were analyzed. Sixty patients (74%) were successfully reached and completed the PRO form at median postoperative day 356 (range: 43 to 818). Eight patients (13% of patients with PRO data) claimed to have both a bulge and pain at their previous hernia site, concerning for possible recurrence. Median overall HerQLes score was 82 [Interquartile Range (IQR): 54 to 99]. Patients with a single hernia defect, when compared with those with multiple defects, had a lower rate of both a bulge (15% vs. 30%) and symptoms (33% vs. 48%), as well as a higher median HerQLes score (85 vs. 62) at the time of PRO follow-up. Patients with previous hernia repair had a lower median HerQLes score of 65 (IQR: 43 to 90) versus 88 (IQR: 62-100). These patients also had a higher rate of sensing a bulge (29% vs. 18%), whereas a sense of symptoms at the site was less (33% vs. 44%). CONCLUSIONS: Barbed suture for fascial defect closure in rVHR was found to be safe with an acceptable rate of possible recurrence by the use of PRO data. Patients with multiple hernias and previous repairs had a higher likelihood of recurrence and a lower quality of life after rVHR.