Clinical outcomes and costs of retromuscular and intraperitoneal onlay mesh techniques in robotic incisional hernia repair.

BACKGROUND: This study aims to compare clinical outcomes and financial cost of intraperitoneal onlay mesh (IPOM) versus retromuscular (RM) repairs in robotic incisional hernia repairs (rIHR). METHODS: Patients who underwent either IPOM or RM elective rIHR from 2012 to 2022 were included. Demographics, operative details, postoperative outcomes, and hospital costs were directly compared. RESULTS: Sixty-nine IPOM and 55 RM were included. Age and body mass index (BMI) did not differ between both groups (IPOM vs RM: 59.3 ± 11.2 years vs. 57.5 ± 14 years, p = 0.423; BMI 34.1 ± 6.3 vs. BMI 33.2 ± 6.9, p = 0.435, respectively). Comorbidities and hernia characteristics were comparable. Extensive lysis of adhesions (> 30 min) was required more often in IPOM (18 vs. 6 in RM, p = 0.034). Defect closure was achieved in 100% of RM vs. 81.2% in IPOM (p < 0.001). Median (interquartile range) postoperative pain score was higher in RM than in IPOM [5(3-7) vs. 4(3-5), respectively, p = 0.006]. Median length of stay (0 day) and same-day discharge rate did not differ between groups (p = 0.598, p = 0.669, respectively). Six (8.7%) patients in the IPOM group versus one (1.8%) patient in the RM group were readmitted to hospital within 30 days postoperatively (p = 0.099). Perioperative complications were higher in IPOM (p = 0.011; 34.8% vs. 14.5% in RM) with higher Comprehensive Complication Index® morbidity scores [0(0-12.2) vs 0(0-0) in RM, p = 0.008)], Clavien-Dindo grade-II complications (8 vs 0 in RM, p = 0.009), and surgical site events (17 vs. 5 in RM, p = 0.024). Within a follow-up period of 57(± 28) months, recurrence rates were similar between both groups. Hospital costs did not differ between groups [IPOM: $9978 (7031-12,926) vs. RM: $8961(6701-11,222), p = 0.300]. Although postoperative complication costs were higher in IPOM ($2436 vs RM: $161, p = 0.020), total costs were comparable [IPOM: $12,415(8700-16,130) vs. RM: $9123(6789-11,457), p = 0.080]. CONCLUSION: Despite retromuscular repairs having lower postoperative complications than intraperitoneal onlay mesh repairs, both techniques offered encouraging results in robotic incisional hernia repair at a comparable total cost.

Nationwide Readmissions Analysis of Minimally Invasive Versus Open Ventral Hernia Repair: A Retrospective Population-Based Study.

INTRODUCTION: Minimally invasive ventral hernia repair (MISVHR) has been performed for almost 30 years; recently, there has been an accelerated adoption of the robotic platform leading to renewed comparisons to open ventral hernia repair (OVHR). The present study evaluates patterns and outcomes of readmissions for MISVHR and OVHR patients. METHODS: The Nationwide Readmissions Database (NRD) was queried for patients undergoing OVHR and MISVHR from 2016 to 2018. Demographic characteristics, complications, and 90-day readmissions were determined. A subgroup analysis was performed to compare robotic ventral hernia repair (RVHR) vs laparoscopic hernia repair (LVHR). Standard statistical methods and logistic regression were used. RESULTS: Over the 3-year period, there were 25 795 MISVHR and 180 635 OVHR admissions. Minimally invasive ventral hernia repair was associated with a lower rate of 90-day readmission (11.3% vs 17.3%, P < .01), length of stay (LOS) (4.0 vs 7.9 days, P < .01), and hospital charges ($68,240 ± 75 680 vs $87,701 ± 73 165, P < .01), which remained true when elective and non-elective repairs were evaluated independently. Postoperative infection was the most common reason for readmission but was less common in the MISVHR group (8.4% vs 16.8%, P < .01). Robotic ventral hernia repair increased over the 3-year period and was associated with decreased LOS (3.7 vs 4.1 days, P < .01) and comparable readmissions (11.3% vs 11.2%, P = .74) to LVHR, but was nearly $20,000 more expensive. In logistic regression, OVHR, non-elective operation, urban-teaching hospital, increased LOS, comorbidities, and payer type were predictive of readmission. CONCLUSIONS: Open ventral hernia repair was associated with increased LOS and increased readmissions compared to MISVHR. Robotic ventral hernia repair had comparable readmissions and decreased LOS to LVHR, but it was more expensive.

Outcomes of a Presurgical Optimization Program for Elective Hernia Repairs Among High-risk Patients.

Importance: Preoperative optimization is an important clinical strategy for reducing morbidity; however, nearly 25% of persons undergoing elective abdominal hernia repairs are not optimized with respect to weight or substance use. Although the preoperative period represents a unique opportunity to motivate patient health behavior changes, fear of emergent presentation and financial concerns are often cited as clinician barriers to optimization. Objective: To evaluate the feasibility of evidence-based patient optimization before surgery by implementing a low-cost preoperative optimization clinic. Design, Setting, and Participants: This quality improvement study was conducted 1 year after a preoperative optimization clinic was implemented for high-risk patients seeking elective hernia repair. The median (range) follow-up was 197 (39-378) days. A weekly preoperative optimization clinic was implemented in 2019 at a single academic center. Referral occurred for persons seeking elective hernia repair with a body mass index greater than or equal to 40, age 75 years or older, or active tobacco use. Data analysis was performed from February to July 2020. Exposures: Enrolled patients were provided health resources and longitudinal multidisciplinary care. Main Outcomes and Measures: The primary outcomes were safety and eligibility for surgery after participating in the optimization clinic. The hypothesis was that the optimization clinic could preoperatively mitigate patient risk factors, without increasing patient risk. Safety was defined as the occurrence of complications during participation in the optimization clinic. The secondary outcome metric centered on the financial impact of implementing the preoperative optimization program. Results: Of the 165 patients enrolled in the optimization clinic, most were women (90 patients [54.5%]) and White (145 patients [87.9%]). The mean (SD) age was 59.4 (15.8) years. Patients' eligibility for the clinic was distributed across high-risk criteria: 37.0% (61 patients) for weight, 26.1% (43 patients) for tobacco use, and 23.6% (39 patients) for age. Overall, 9.1% of persons (15 patients) were successfully optimized for surgery, and tobacco cessation was achieved in 13.8% of smokers (8 patients). The rate of hernia incarceration requiring emergent surgery was 3.0% (5 patients). Economic evaluation found increased operative yield from surgical clinics, with a 58% increase in hernia-attributed relative value units without altering surgeon workflow. Conclusions and Relevance: In this quality improvement study, a hernia optimization clinic safely improved management of high-risk patients and increased operative yield for the institution. This represents an opportunity to create sustainable and scalable models that provide longitudinal care and optimize patients to improve outcomes of hernia repair.

Value Analysis of Methods of Inguinal Hernia Repair.

OBJECTIVE: Value is defined as health outcomes important to patients relative to cost of achieving those outcomes: Value = Quality/Cost. For inguinal hernia repair, Level 1 evidence shows no differences in long-term functional status or recurrence rates when comparing surgical approaches. Differences in value reside within differences in cost. The aim of this study is to compare the value of different surgical approaches to inguinal hernia repair: Open (Open-IH), Laparoscopic (Lap-IH), and Robotic (R-TAPP). METHODS: Variable and fixed hospital costs were compared among consecutive Open-IH, Lap-IH, and R-TAPP repairs (100 each) performed in a university hospital. Variable costs (VC) including direct materials, labor, and variable overhead ($/min operating room [OR] time) were evaluated using Value Driven Outcomes, an internal activity-based costing methodology. Variable and fixed costs were allocated using full absorption costing to evaluate the impact of surgical approach on value. As cost data is proprietary, differences in cost were normalized to Open-IH cost. RESULTS: Compared to Open-IH, VC for Lap-IH were 1.02X higher (including a 0.81X reduction in cost for operating room [OR] time). For R-TAPP, VC were 2.11X higher (including 1.36X increased costs for OR time). With allocation of fixed cost, a Lap-IH was 1.03X more costly, whereas R-TAPP was 3.18X more costly than Open-IH. Using equivalent recurrence as the quality metric in the value equation, Lap-IH decreases value by 3% and R-TAPP by 69% compared to Open-IH. CONCLUSIONS: Use of higher cost technology to repair inguinal hernias reduces value. Incremental health benefits must be realized to justify increased costs. We expect payors and patients will incorporate value into payment decisions.

Healthcare Resource Utilization in Inguinal Hernia Repair: A Three-Year Cost Evaluation of Truven Health Marketscan Research Databases.

BACKGROUND: Inguinal hernia repair is the most commonly performed elective operation in the United States, with over 800,000 cases annually. While clinical outcomes comparing laparoscopic versus open techniques have been well documented, there is little data comparing costs associated with these techniques. This study evaluates the cost of healthcare resources during the 90-d postoperative period following inguinal hernia repair. METHODS: We analyzed data from the Truven Health MarketScan Research Databases. Adult patients with an ICD-9 or CPT code for inguinal hernia repair from 2012 to 2014 were included. Patients with continuous enrollment for 6 mo prior to surgery and 6 mo after surgery were analyzed. Related healthcare service costs (readmission and/or ER visit and/or outpatient visit) were calculated by clinical classification software and generalized linear modeling was used to compare healthcare utilization between groups. RESULTS: 124,582 cases were identified (open = 84,535; lap = 40,047). Index surgery cost was 41% higher in laparoscopic cases. The cost for readmission was close to $25,000 and similar between both groups, but the laparoscopic group were 12% less likely to be readmitted for surgical complications within 90-d when compared to the open group. Cost of bilateral laparoscopic repair is less than that of serial unilateral open repairs. CONCLUSION: Laparoscopic inguinal hernia repair carries a higher index surgery cost than open repair. However, open repair has an increased rate of readmission. To maximize value, efforts should be directed at minimizing readmissions and improving identification of bilateral hernias at the time of initial presentation.

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.

Establishment of Single-Port, Laparoscopic, Pediatric Hernia Repair in a Developing Country.

Background: Single-port, laparoscopic, needle-assisted, inguinal hernia repair (LNAR) in children intends to reduce surgical trauma and enables contralateral assessment and closure of contralateral patent processus vaginalis if necessary. The aim of the present study was to demonstrate that laparoscopic inguinal repair can be performed safely and cost-effectively in a developing country where laparoscopy is not yet commonly used. Methods: In this single-center study, we included all children undergoing LNAR between January 2017 and December 2018. Intraoperative and postoperative complications and hospital costs were assessed. Results: We performed 148 hernia repair operations in 117 children (age range 1 month to 15 years). Mean operative time was 20.8 ± 9.4 minutes. Mean length of hospital stay amounted to 10 ± 7.6 hours, with 77.7% of patients discharged within 6 hours. No intraoperative complications occurred in any patient. Complications occurred in six (5.1%) patients. Three (2.5%) patients experienced residual hydrocele, two (1.4%) patients suffered wound site seroma, and one (0.67%) patient experienced recurrent inguinal hernia 6 months after the initial repair. All complications occurred during the first year of the study period. Likewise, operative time (P < .0001) as well as duration of hospital stay (P < .0001) was significantly shorter in the second year. Total costs for complete treatment were below USD 80 per patient, which is comparable with the costs associated with open herniotomy at the same institution. Conclusion: Single-port LNAR and hydrocele repair in children were established safely and cost-effectively in a developing country. Nevertheless, the procedure was associated with a steep learning curve.

Using Local Anesthesia for Inguinal Hernia Repair Reduces Complications in Older Patients.

BACKGROUND: Inguinal hernia repair is the most common general surgery operation in the United States. Nearly 80% of inguinal hernia operations are performed under general anesthesia versus 15%-20% using local anesthesia, despite the absence of evidence for the superiority of the former. Although patients aged 65 y and older are expected to benefit from avoiding general anesthesia, this presumed benefit has not been adequately studied. We hypothesized that the benefits of local over general anesthesia for inguinal hernia repair would increase with age. MATERIALS AND METHODS: We analyzed 87,794 patients in the American College of Surgeons National Surgical Quality Improvement Project who had elective inguinal hernia repair under local or general anesthesia from 2014 to 2018, and we used propensity scores to adjust for known confounding. We compared postoperative complications, 30-day readmissions, and operative time for patients aged <55 y, 55-64 y, 65-74 y, and ≥75 y. RESULTS: Using local rather than general anesthesia was associated with a 0.6% reduction in postoperative complications in patients aged 75+ y (95% CI -0.11 to -1.13) but not in younger patients. Local anesthesia was associated with faster operative time (2.5 min - 4.7 min) in patients <75 y but not in patients aged 75+ y. Readmissions did not differ by anesthesia modality in any age group. Projected national cost savings for greater use of local anesthesia ranged from $9 million to $45 million annually. CONCLUSIONS: Surgeons should strongly consider using local anesthesia for inguinal hernia repair in older patients and in younger patients because it is associated with significantly reduced complications and substantial cost savings.

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures.

OBJECTIVE: The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. SUMMARY BACKGROUND DATA: Reducing surgical costs is paramount to the viability of hospitals. METHODS: Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons. RESULTS: The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy. CONCLUSIONS: Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

Robotic-assisted repair of complex ventral hernia: can it pay off?

Pressure on health care providers is growing due to capping of remuneration for medical services in most Western European countries. We wanted to investigate, if robotic-assisted ventral hernia repair is reasonable from an economic point of view in our setting. Patients undergoing open or robotic-assisted repair for complex abdominal wall hernia using a Transversus Abdominis Release (TAR) between September 2017 and January 2019 were included. Procedure-related costs were calculated exact to the minute and cost unit accounting for the postoperative in-patient stay was done. Abdominal wall reconstruction using the TAR-technique was done in a total of 26 (10 female) patients via an open (n = 10) or robotic-assisted (n = 16) approach. No significant difference was seen in regard to age, BMI and ASA scores between subgroups. Time for operation was longer (253.5 vs 211.5 min; p = 0.0322), while postoperative hospital stay was shorter for patients operated with a robotic-assisted approach (4.5 vs 12.5 days; p < 0.005). Procedure-related costs were 2.7-fold higher when a robotic-assisted reconstruction was done (EUR 5397 vs. 1989), while total costs for in-patient stay were about 60% lower (EUR 2715 vs 6663). Currently, revenues by national insurance account for a total of EUR 9577 leading to a profit of EUR 1465 and 925 for the robotic-assisted and open myofascial release, respectively. In addition, 30-day re-admission rate was in favor of the robotic-assisted approach as well (6.3% vs 20%). From an economic point of view, robotic-assisted TAR for complex ventral hernia repair is a viable option in our setting. Higher procedure-related costs are offset by a significant shorter hospital stay. The economic advantage goes along with improvement in outcome of patients.

Robotic Inguinal Hernia Repair Outcomes: Operative Time and Cost Analysis.

BACKGROUND: Robotic inguinal hernia repair is the latest iteration of minimally invasive herniorrhaphy. Previous studies have shown expedited learning curves compared to traditional laparoscopy, which may be offset by higher cost and longer operative time. We sought to compare operative time and direct cost across the evolving surgical practice of 10 surgeons in our healthcare system. METHODS: This is a retrospective review of all transabdominal preperitoneal robotic inguinal hernia repairs performed by 10 general surgeons from July 2015 to September 2018. Patients requiring conversion to an open procedure or undergoing simultaneous procedures were excluded. The data was divided to compare each surgeon's initial 20 cases to their subsequent cases. Direct operative cost was calculated based on the sum of supplies used intra-operatively. Multivariate analysis, using a generalized estimating equation, was adjusted for laterality and resident involvement to evaluate outcomes. RESULTS: Robotic inguinal hernia repairs were divided into two groups: early experience (n = 167) and late experience (n = 262). The late experience had a shorter mean operative time by 17.6 min (confidence interval: 4.06 - 31.13, p = 0.011), a lower mean direct operative cost by $538.17 (confidence interval: 307.14 - 769.20, p < 0.0001), and fewer postoperative complications (p = 0.030) on multivariate analysis. Thirty-day readmission rates were similar between both groups. CONCLUSION: Increasing surgeon experience with robotic inguinal hernia repair is associated with a predictable reduction in operative time, complication rates, and direct operative cost per case. Thirty-day readmission rates are not affected by the learning curve.

Laparoscopic hiatal hernia repair as same day surgery: Feasibility, short-term outcomes and costs.

INTRODUCTION: Laparoscopic hiatal hernia repair is commonly performed with 1 night hospitalization. The aim was to assess repairs as same-day-surgery (SDS). METHODS: Costs/short-term outcomes of SDS were compared to hospital-stay < 24-h: observation (OBS) and hospital-stay ≥ 24-h: inpatient (INP). Outcomes were assessed by postoperative 30-day ER visits/readmissions. RESULTS: There were 262 procedures, excluding 50 reoperative repairs, 212 procedures were included: There were 66 SDS, 65 OBS and 81 INP. SDS vs. OBS: OBS were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. SDS vs. INP: INP were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. CONCLUSION: Laparoscopic hiatal hernia repair can be performed as SDS in majority of elective repairs with good short-term outcomes and reduced cost.

[Minimally invasive ventral hernia repair: apply or save?] / Maloinvazivnye tekhnologii v gerniologii: primenyat' nel'zya ekonomit'.

Treatment of patients with ventral hernias remains one of the most pressing problems of abdominal surgery. Surgeons are trying to find a «gold standard¼ for the treatment of this pathology. Great hopes are placed on minimally invasive techniques, however, due to their high cost, they do not yet find mass distribution in everyday practice. In our opinion, this is short-sighted. We tried to analyze the feasibility of using minimally invasive techniques in the treatment of patients with ventral hernias of various locations, from the position of clinical and economic efficiency.

Technique and outcome of day case laparoscopic hiatus hernia surgery for small and large hernias: a five-year retrospective review from a high-volume UK centre.

INTRODUCTION: Laparoscopic anti-reflux surgery is the standard surgical treatment for gastro-oesophageal reflux disease in patients for who long-term pharmacotherapy is intolerable or ineffective. Advances in anaesthesia and minimally invasive surgery have led to day case treatment being adopted by some centres. The objective of this study is to describe our day case pathway and peri- and postoperative outcomes. MATERIALS AND METHODS: This is a single centre, retrospective case series review of a prospectively collected database from October 2014 to August 2019 performed in a tertiary centre for upper gastrointestinal surgery. Data collected included demographics, comorbidities, indications, complications, length of stay and readmission. RESULTS: A total of 362 patients underwent laparoscopic anti-reflux surgery with or without hiatus hernia repair of up to 10cm, with day case rates of 59%. Unplanned admission following day surgery was 5.1% (13/225) and 30-day readmission was 2.2% (8/362); 90.6% of patients remained in hospital for less than 24 hours. There was one intraoperative complication and one patient required revisional surgery within 30 days. The rate of all postoperative complications was 1.38% (5/362) with one postoperative mortality. DISCUSSION: The inclusion of larger hernias is unusual, as most studies limit size to 5cm or less. Our results show the safety and feasibility of the procedure even when applied to hiatus hernias up to 10cm. Success was multifactorial and based on standardisation of procedures and support from dedicated specialist nursing staff. CONCLUSION: Laparoscopic anti-reflux surgery can be performed safely as a day case procedure even in larger hiatus hernias, with a dedicated care pathway and specialist nurse practitioners to support it.

Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project.

OBJECTIVE: to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital. METHODS: retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System. RESULTS: surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction). CONCLUSION: there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

Age-Dependent Costs and Complications in Pediatric Umbilical Hernia Repair.

OBJECTIVES: To characterize regional variation in the age of patients undergoing umbilical hernia repair to determine costs and subsequent care. STUDY DESIGN: We performed a cross-sectional descriptive study using a large convenience sample of US employer-based insurance claims from July 2012 to December 2015. We identified children younger than 18 years of age undergoing uncomplicated (not strangulated, incarcerated, or gangrenous) umbilical hernia repair as an isolated procedure (International Classification of Diseases, Ninth Revision procedure codes 53.41, 53.42, 53.43, or 53.49, International Classification of Diseases, Tenth Revision procedure code 0WQF0ZZ, or Current Procedural Terminology procedure codes 49580 or 49585). RESULTS: In all, 5212 children met criteria for inclusion. Children younger than age 2 years accounted for 9.7% of repairs, with significant variation by census region (6% to 14%, P < .001). Total payments for surgery varied by age; children younger than 2 years averaged $8219 and payments for older children were $6137. Postoperative admissions occurred at a rate of 73.1 per 1000 for children younger than age 2 years and 7.43 for older children; emergency department visits were 41.5 per 1000 for children younger than age 2 years vs 15.9 for older children (P < .001). CONCLUSIONS: Umbilical hernias continue to be repaired at early ages with large regional variation. Umbilical hernia repair younger than age 2 years is associated with greater costs and greater frequency of postoperative hospitalization and emergency department visits.

Robotic versus laparoscopic ventral hernia repair: multicenter, blinded randomized controlled trial.

OBJECTIVE: To determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair. DESIGN: Pragmatic, blinded randomized controlled trial. SETTING: Multidisciplinary hernia clinics in Houston, USA. PARTICIPANTS: 124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019. INTERVENTIONS: Robotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59). MAIN OUTCOME MEASURES: The primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat. RESULTS: Patients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair. CONCLUSION: This study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs. TRIAL REGISTRATION: Clinicaltrials.gov NCT03490266.

A Novel University of North Carolina Laparoscopic Ventral Hernia Repair Simulator.

Background: Simulation plays an important role in surgical training. We developed a simulator for laparoscopic ventral hernia repair (LVHR) surgery based on porcine tissue, characterized by low cost and high reality. Methods: Our LVHR model is based on porcine tissue mounted in a human mannequin. The anterior abdominal wall is constructed to allow laparoscopic training. Training sessions are conducted in a simulated operating room environment. Results: During preliminary tests, the LVHR simulator was found to be highly realistic in terms of tissue feedback, instrumentation usage, and performing the key steps of the LVHR procedure. The model was evaluated as a very useful tool for residents' training allowing to gain laparoscopic skills, learn the key steps of LVHR, and practice team work. Conclusions: Our simulator, based on porcine tissue mounted in a mannequin, offers a very realistic and cost-effective model for simulating LVHR surgery.