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.

Is previous prostatectomy a risk factor for postoperative complications following minimally invasive inguinal hernia repair? A systematic review and meta-analysis.

AIM: The literature indicates that patients with prior pelvic surgery, particularly radical prostatectomy, pose challenges in minimally invasive inguinal hernia repair (IHR). However, there is no conclusive evidence regarding the impact of pelvic surgery on postoperative complications. To address this gap, we conducted a systematic review and meta-analysis to evaluate the influence of previous prostatectomy in men undergoing MIS IHR. MATERIALS AND METHODS: We searched Cochrane Central, Scopus, SciELO, Lilacs, and PubMed/MEDLINE for studies comparing men undergoing MIS IHR after prostatectomy with men without previous pelvic surgery. Key outcomes evaluated included recurrence, overall postoperative complications, seroma, hematoma, surgical site infection (SSI), conversion rates, and operative time. RESULTS: Out of 402 screened studies, 9 met the inclusion criteria. Among the included studies, three analyzed totally extraperitoneal (TEP) technique, while four analyzed transabdominal preperitoneal (TAPP) and two presented both techniques together. The analysis comprised 189,183 patients, of which 4551 (2.4%) had a history of prostatectomy. The analysis revealed that post-prostatectomy patients presented higher postoperative complications (3.7% vs. 1.9%; RR 1.9; 95% CI [1.23; 2.94]; P = 0.004) and seroma (1.6% vs. 0.9%; RR 1.58; 95% CI [1.23; 2.04]; P < 0.001) following MIS IHR. Additionally, patients with a previous prostatectomy presented an increased operative time (MD 21.25 min; 95% CI [19.1; 23.4]; P < 0.001). No significant differences were observed in recurrence (0.98% vs. 0.92%; RR 1.1; 95% CI [0.8; 1.53]; P = 0.54), SSI (0.07% VS. 0.07%; RR 0.99; 95% CI [0.34; 2.9]; P = 0.98), hematoma (3.6% vs. 1.2%; RR 3.18; 95% CI [0.84; 12.1]; P = 0.09), and conversion rates (1.1% vs. 0.9%; RR 1.26; 95% CI [0.91; 1.72]; P = 0.16). However, subgroup analysis of TEP technique in patients with previous prostatectomy showed higher conversion rates (2.4% vs. 0%; RR 20; 95% CI [2.9; 138.2]; P < 0.01). Analysis using funnel plots showed the absence of publication bias in the study outcomes. CONCLUSION: This comprehensive analysis indicates that patients with a history of prostatectomy undergoing MIS IHR may present higher postoperative complications and an increased operative time. Further comparative studies are needed to evaluate the cumulative impact of MIS IHR in patients with previous prostatectomy.

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.

Navigating hernia sac management in minimally invasive inguinal hernia repair: to abandon or to reduce? An updated systematic review and meta-analysis.

AIM: Minimally invasive inguinal hernia repair has become increasingly accepted, demonstrating superior outcomes over open procedures in postoperative complications. However, certain postoperative complications, such as seroma, remain a dilemma, with many attributing it to the management of the hernia sac. We aimed to perform a systematic review and meta-analysis comparing the reduction versus abandonment of the hernia sac during laparoscopic inguinal hernia repair. MATERIAL AND METHODS: Cochrane, Scopus, SciELO, and PubMed were searched for studies comparing reduction and abandonment of the hernia sac. Our primary outcome was seroma. Secondary outcomes were overall complications, postoperative pain, surgical site infection, recurrence, hospital length of stay (LOS), and operative time. We performed a subgroup analysis of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. Statistical analysis was performed with R Studio. RESULTS: 2388 studies were screened, and seven studies were included, comprising 3153 patients, of which 916 (29%) were in the abandonment group. We found higher seroma rates for the abandonment group (RR 1.52; 95% CI 1.22 to 1.89; P < 0.001). No differences were found in overall complications (RR 0.88; 95% CI 0.55 to 1.42; P = 0.61), postoperative pain (RR 1.15; 95% CI 0.46 to 2.87; P = 0.76), recurrence (RR 2.67; 95% CI 0.51 to 14.05; P = 0.25), operative time (MD - 4.45 min; 95% CI - 12.77 to 3.86; P = 0.29), and LOS (MD -0.06 days; 95% CI - 0.14 to 0.02; P = 0.14) between both groups. Subgroup analysis of seroma showed no differences between the groups when analyzing TAPP (19.3% vs. 13%; RR 1.65; 95% CI 0.91 to 2.99; P = 0.1) and TEP (9% vs. 4.3%; RR 1.69; 95% CI 0.62 to 4.6; P = 0.3) procedures. CONCLUSION: Our systematic review and meta-analysis support that hernia sac abandonment may be associated with increased early seroma rates following laparoscopic inguinal hernia repair, but limited data are available for technique-specific analyses.

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.

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.

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.

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.

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

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

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

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

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.

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

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

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

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

Initial experience using a handheld fully articulating software-driven laparoscopic needle driver in TAPP inguinal hernia repair.

BACKGROUND: The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a widely performed minimally invasive operation, but can present considerable ergonomic challenges for the surgeon. Our objective was to determine if a novel handheld software-driven laparoscopic articulating needle driver can mitigate these difficulties. METHODS: The video recordings of a consecutive series of TAPP cases by a single surgeon using the articulating device were compared with a series of cases using straight-stick laparoscopy. Two critical steps of the procedure were analyzed for time: mesh fixation and peritoneal suture closure. These steps were then compared before and after 10 initial consecutive cases to analyze whether the surgeon demonstrated improvement. A cost analysis was also performed between the two techniques. RESULTS: For mesh fixation, the surgeon averaged 227 s using tacker devices, compared with 462.4 s using the novel laparoscopic device (p = 0.06). For the peritoneal closure component of the operation, the surgeon improved the time per suture pass during closure from 60.61 s during the first 10 cases to 38.84 s after the first 10 cases (p = 0.0004), which was comparable to the time per stitch for standard laparoscopy (34.8 s vs 34.84 s, p = 0.997). Left-sided inguinal hernia repairs using the articulating device demonstrated a significantly longer time per stitch during peritoneal closure compared to the right side after first 10 cases (left: 40.62 s; right: 27.91, p = 0.005). Our direct cost analysis demonstrated that suture closure of the peritoneum using the articulating device was more cost-effective than tack fixation. CONCLUSIONS: After only a 10 case initial experience, a laparoscopic hand-held articulating needle driver is comparable to standard laparoscopy to complete suture mesh fixation and peritoneal closure for TAPP inguinal hernia repair. Further, the feasibility of suture mesh fixation minimizes the need for costly tacker devices. This instrument appears to be a promising tool in this largely minimally invasive era of hernia repair.

SubCutaneous OnLay endoscopic Approach (SCOLA) mesh repair for small midline ventral hernias with diastasis recti: An initial US experience.

BACKGROUND: Patients presenting for evaluation of umbilical and epigastric hernias are often found to have diastasis recti (DR). As isolated hernia repair in these patients may be associated with higher rates of recurrence, prior international publications have described a prefascial mesh repair in combination with anterior plication of DR. We present our initial United States (US) experience with a SubCutaneous OnLay endoscopic Approach (SCOLA) to address these concurrent pathologies in a single hybrid procedure. METHODS: Between July 2018 and December 2019, a prospective cohort of 16 patients underwent the SCOLA procedure. Subcutaneous dissection was carried out from the suprapubic region superiorly to the xiphoid process and laterally to the linea semilunaris. Hernia contents were reduced and defects were incorporated into anterior DR plication, which was performed with running barbed suture. Onlay mesh was placed to cover the entire dissected space, and subcutaneous drains were placed. Three separate attendings performed cases with one supervising attending for standard technique. RESULTS: Of 16 patients, 14 (87.5%) were female. The mean age was 45.7 (11.9) years; mean BMI was 29.0 (3.6) kg/m2. The mean hernia defect size was 1.9 (0.7) cm. Mean operative time was 146 (46.3) minutes; two (15%) cases were performed robotically. The mean follow-up time was approximately two months (63 days). Three (18.8%) patients developed seroma, one (6.3%) patient developed an infected seroma, and two (12.5%) patients developed hernia recurrence. CONCLUSIONS: SCOLA technique is shown to be a safe and effective approach for patients presenting with small midline ventral hernias and concomitant DR. Our preliminary US data demonstrates higher rates of post-operative complication in patients with higher BMI, which suggests that patient selection and pre-operative counseling is essential to achieve better technical outcomes in our patient population.

Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review.

BACKGROUND: A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different countries. The aim of this systematic review is to assess the safety and feasibility of different named techniques with the same surgical concept. METHODS: The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score system was 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 designs, risk of bias, publication bias, heterogeneity, and statistical analysis. RESULTS: The systematic literature search found 2548 articles, 317 of which were duplicates and excluded from analysis. The titles and abstracts from the remaining 2231 articles were assessed. After careful evaluation, 2125 articles were determined to be unrelated to our study and subsequently excluded. The full text of the remaining 106 articles was thoroughly assessed. Case reports, editorials, letters to the editor, and general reviews were then excluded. A total of 13 articles were ultimately included for this review, describing a similar subcutaneous endoscopic approach for repair of concomitant ventral hernias and rectus diastasis defined under nine different named techniques on 716 patients. The number of patients in those studies varied from 10 to 201. The mean operative time varied from 68.5 to 195 min. The most common complication was seroma, followed by pain requiring intervention, hematoma, and surgical site infection. CONCLUSIONS: There are a few technique variations described in different studies, but with no significant differences in outcomes. We, therefore, propose to unify these procedures under one term, ENDoscopic Onlay Repair (ENDOR). This technique has shown to be effective and safe, with seroma being the most common complication.

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide.

BACKGROUND: Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair. METHODS: Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way. CONCLUSIONS: As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.

The influence of social media in minimally invasive surgery education: How surgeons exchange experience and knowledge in these platforms.

Engagement with social media is increasing within medical professionals. There are many different platforms, such as Facebook, Instagram, Whatsapp, Twitter, Telegram, and so on. Social media is a new and important tool for surgical education. More and more surgeons are joining restricted groups to discuss surgical techniques, manuscripts, etc in a daily basis. It is important that residents and surgeons have a very critical opinion about what they look online. Not everything is good or feasible.

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.