Initial experience with enhanced recovery after surgery (ERAS) and early discharge protocols after robotic extended totally extraperitoneal (eTEP) hernia surgery.

BACKGROUND: Though robotic adoption for eTEP surgery has decreased technical barriers to minimally invasive repairs of large ventral hernias, relatively few studies have examined outcomes of robotic-specific eTEP surgery. This study evaluates safety, feasibility, and early outcomes of ERAS/same-day discharge protocols for robotic eTEP ventral hernia repairs. METHODS: A retrospective chart review was performed for all robotic eTEP hernia surgeries at a single institution between 2019 and 2022. Analysis included patient demographics, hernia characteristics, intraoperative data, and post-operative outcomes at 30 days. ERAS protocol included: judicious use of urinary catheters with removal at end of case if placed, bilateral transversus abdominus plane (TAP) blocks, post-operative abdominal wall binder, and opioid-sparing perioperative analgesia. Patients were discharged same day from post-anesthesia care unit (PACU) if they lacked comorbidities requiring observation post-anesthesia and demonstrated stable vital signs, adequate pain control, ability to void, and ability to ambulate. Hospital length of stay (LOS) was considered 0 for same-day PACU discharges or hospitalizations < 24 h. RESULTS: 102 patients were included in this case series. 69% (70/102) of patients were discharged same-day (mean LOS 0.47 ± 0.80 days). Within 30 post-operative days, 3% (3/102) of patients presented to the ER, 2% (2/102) were readmitted to the hospital, and 1% (1/102) required reoperation. There was 1 serious complication (Clavien-Dindo grade 3/4) with an aggregate complication rate of 7.8%. CONCLUSIONS: Our initial experience with ERAS protocols and same-day discharges after robotic eTEP repair demonstrates this approach is safe and feasible with acceptable short-term patient outcomes. Compared to traditional open surgery for large ventral hernias, robotic eTEP may enable significant reductions in hospital LOS as adoption increases.

Early results of eTEP access surgery with preperitoneal repair of primary midline ventral hernias and diastasis recti. A 33 patient case series of "PeTEP".

BACKGROUND: This article aims to share the initial experience of the preperitoneal eTEP approach and its potential benefits in a selected group of patients. The eTEP Rives-Stoppa is a proven minimally invasive surgical technique for the treatment of ventral midline and off-midline hernias that has shown to be a solid, durable, and reproducible repair. The preperitoneal eTEP repair is a surgical technique that brings together the extraperitoneal access surgery with a preperitoneal repair for primary midline hernias avoiding posterior rectus sheath division and preservation of the retrorectus space while being able to treat simultaneous diastasis recti. METHODS: The analysis included 33 patients operated with the preperitoneal eTEP approach from September 2022 to September 2023 in patients with primary small to medium (< 4 cm) midline hernias, single or multiple defects with or without diastasis recti. Age, gender, hernia characteristics, operative time, and surgical site occurrences will be discussed, as well as fine details and landmarks in the operative technique. RESULTS: 33 consecutive patients were operated, 19 female (57.5%) and 14 males (42.5%) between 32 and 63 years of age, the most common comorbidity found was obesity (BMI > 30). In 70% of the cases, operative time was 90 min ± 25 min. The average hospital stay was one day, while 12 went home the same day, and so far, no reoccurrences have been reported. CONCLUSIONS: We believe the preperitoneal eTEP approach for small to medium primary midline hernias is an effective and solid repair that combines excellent features of proven surgical techniques and eliminates the need for posterior rectus sheath division while saving the retrorectus space, among other benefits that will be discussed. The reproducibility of the technique remains to be proven.

Comparing procedural costs and early clinical outcomes of robotic extended totally extraperitoneal (eTEP) with intraperitoneal onlay mesh (IPOM) repair for midline ventral hernias.

INTRODUCTION: The extended totally extraperitoneal (eTEP) repair has several theoretical advantages over the traditional intraperitoneal onlay mesh (IPOM) repair for ventral hernias, including the use of less expensive non-barrier coated mesh and avoiding complications of intraperitoneal mesh. However, one area in need of further investigation is cost and clinical comparisons following robotic eTEP with IPOM. METHODS: A retrospective matched cohort study was conducted of patients with midline ventral hernias undergoing robotic eTEP or IPOM at a single academic institution from November 2019-August 2023. Patients were matched based on demographics, hernia defect size, and whether they underwent concomitant procedures. Primary outcomes included supply costs. Secondary outcomes included operative time, length of stay, complications, recurrence, and inpatient opioid utilization. RESULTS: In total, 88 matched patients were included: 44 IPOM and 44 eTEP. Mean age was 57 years, BMI 35 kg/m2, and 54.5% were male. Hernia size was similar for both groups: 25 [6-73] cm2 for the IPOMs vs 40 [14-68] cm2 for eTEPs (p = 0.21). There was no significant difference in total supply costs between IPOMs and eTEPs: $2338 [2021-3249] vs $2082 [1619-3394] (p = 0.5) respectively. Mean operative time was significantly lower for IPOMs 159.6 ± 57.8 min vs 198.0 ± 67.1 (p = 0.006), while the average length of stay was significantly longer for IPOMs: 1.7 ± 1.2 days vs 1.2 ± 1.3 days (p = 0.021). Total inpatient MME utilized was greater for IPOM: 61 [36-102] vs 29 [10-64] MME (p = 0.003). Postoperative complications and recurrence rate were similar. CONCLUSION: There is no difference in total supply costs between patients undergoing robotic IPOM and eTEP repairs for midline ventral hernias. Though this study did find significant differences in total inpatient MME utilized and length of stay, it is debatable whether these are clinically significant. Further research is needed to determine appropriate indications for eTEP over IPOM.

eTEP Rives-Stoppa impact on abdominal contour: a retrospective observational and clinical quality improvement study using Ellipse 9 tool.

BACKGROUND: The eTEP Rives-Stoppa (RS) procedure, increasingly used for ventral hernia repair, has raised concerns about postoperative upper abdominal bulging. This study aims to objectively evaluate changes in the abdominal contour after eTEP RS and explore potential causes using a novel analytical tool, the Ellipse 9. METHODS: Thirty patients undergoing eTEP RS without posterior rectus sheath closure were assessed before and 3 months after surgery using CT scan images. Key measurements analyzed included the distance between linea semilunaris (X2), eccentricity over the Cord (c/a Cord), superior eccentricity (c/a Sup), Y2, and the superior perimeter of the abdomen. The Ellipse 9 tool, which provides graphical images and numerical representations, was utilized alongside patient-reported outcomes to assess perceived abdominal changes. RESULTS: The study group exhibited a trend toward a flatter abdomen with reduced distance between linea semilunaris(X2). However, 17% of patients developed upper abdominal bulging (5). Significant differences in c/a Cord, c/a Sup, Y2, and the superior perimeter of the abdomen, confirmed with Bonferroni corrections, were noted between bulging (5 patients) and non-bulging groups (25 patients). There was a notable disparity between patient perceptions and objective outcomes. CONCLUSION: The eTEP RS procedure improved abdominal contour in most patients from a selected cohort. The Ellipse 9 tool was valuable for the objective analysis of these changes. The cause of bulging post-eTEP RS is probably multifactorial. Notably, there was often a discrepancy between patient perceptions of bulging and objective clinical findings.

L3W3 Incisional Hernia with LOD - Robotic eTEP-TAR Repair (with video).

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.mp4" type="video/mp4" Your browser does not support the video tag. /video Introduction: The Rives-Stoppa procedure has emerged as the preferred method for ventral hernia repair, and the principles of this technique are similarly applied in minimally invasive surgery using the eTEP (enhanced view totally extraperitoneal) approach. It appears that the eTEP approach offers excellent outcomes in terms of less post-operative pain, faster recovery, and shorter hospital stays for patients undergoing abdominal wall reconstruction (AWR). It's important to note that there are some contra-indications of this procedure. In general, laparoscopic eTEP may not be suitable for cases with large hernias and loss of domain where the working space is limited. In such cases, alternative approaches, such as using a robotic platform, may be considered to ensure an adequate working space for abdominal wall reconstruction (AWR). A robotic platform can create a working space by using the robotic arms as a "laparo-lift," enabling the AWR to be performed. Case Report: In this case, we have a 65-year-old female patient with a BMI of 28.5 who presents with a large incisional hernia with LOD. This hernia is located on the right flank and occurred after a Jalaguier incision. The CT scan provided valuable information regarding the size of the hernia, the remaining volume of the abdominal cavity, and the content of the hernia sac. Based on these radiological details, the LOD diagnosis was confirmed using the Sabbagh equation, which revealed that the hernia volume accounted for 46.47% of the total peritoneal volume. Based on the location, size of the defect, and the EHS classification for incisional hernias, the diagnosis for this case is a Complex incisional hernia of L3 right W3 with LOD. The protocol for optimization in this case involves chemo-relaxation, which refers to the injection of botulinum toxin A (BTA) into the large lateral muscles of the abdomen. This is done approximately 6 weeks before the surgery. Based on the successful reduction of the hernia during the consultation, the decision has been made to perform the Abdominal Wall Reconstruction (AWR) procedure using the robotic eTEP-TAR technique. Conclusion: The post-operative course was favorable, with the patient experiencing early active mobilization, reduced pain, and early return of bowel movement. The patient was discharged the day after the surgery.

[Da Vinci robotic complex in hernia repair surgery]. / Ispol'zovanie roboticheskogo kompleksa Da Vinci v khirurgii gryzh. Opyt kliniki.

OBJECTIVE: To review the first robotic hernia repairs performed at the Ilyinsky Hospital, evolution of this technology, learning curve and early outcomes. MATERIAL AND METHODS: There were 17 procedures at the Ilyinskaya Hospital between 2021 and 2023 (13 men and 4 women). Mean age was 60 years, body mass index 28 kg/m2. ASA grade 1 was observed in 1 patient, grade 2 - 14 ones, grade 3 - 2 patients. Ventral, inguinal and umbilical hernias were diagnosed in 7, 8 and 2 cases, respectively. Ventral hernias required IPOM+ procedure in 3 cases, eTEP-RS procedure in 2 cases and eTEP-RS-TAR procedure in 2 cases. Patients with inguinal hernia underwent transabdominal preperitoneal hernia repair. In case of umbilical hernia, TARUP procedure was performed in 1 case and vTAPP procedure in 1 case. RESULTS: Mean surgery time was 2 hours 38 min (min 1 hour 35 min, max 10 hours 11 min). There was one intraoperative complication (bleeding from epigastric artery). The follow-up period ranged from 3 months to 3 years. There were no recurrent hernias. Postoperative complications were noted in 2 cases. One patient was diagnosed with epididymitis after TAPP, 1 patient - with seroma after eTEP-RS procedure. All complications were relieved by conservative treatment. Bleeding from a. epigastrica inferior was diagnosed after removal of the trocar at the end of surgery. This event required suturing. CONCLUSION: Robotic hernia repair appears to be technically feasible and safe. This approach provides favorable results regarding quality of life and recurrence rate.

Robotic eTEP versus IPOM evaluation: the REVEAL multicenter randomized clinical trial.

BACKGROUND: For small to medium-sized ventral hernias, robotic intraperitoneal onlay mesh (rIPOM) and enhanced-view totally extraperitoneal (eTEP) repair have emerged as acceptable approaches that each takes advantage of robotic instrumentation. We hypothesized that avoiding mesh fixation in a robotic eTEP repair offers an advantage in early postoperative pain compared to rIPOM. METHODS: This is a multi-center, randomized clinical trial for patients with midline ventral hernias ≤ 7 cm, who were randomized to rIPOM or robotic eTEP. The primary outcome was pain (0-10) on the first postoperative day. Secondary outcomes included same-day discharge, length of stay, opioid consumption, quality of life, surgeon workload, and cost. RESULTS: Between November 2019 and November 2021, 100 patients were randomized (49 rIPOM, 51 eTEP) among 5 surgeons. Pain on the first postoperative day [median (IQR): 5 (4-6) vs. 5 (3.5-7), p = 0.66] was similar for rIPOM and eTEP, respectively, a difference maintained following adjustments for surgeon, operative time, baseline pain, and patient co-morbidities (difference 0.28, 95% CI - 0.63 to 1.19, p = 0.56). No differences in pain on the day of surgery, 7, and 30 days after surgery were identified. Same-day discharge, length of stay, opioid consumption, and 30-day quality of life were also comparable, though rIPOM required less surgeon workload (p < 0.001), shorter operative time [107 (86-139) vs. 165 (129-212) min, p < 0.001], and resulted in fewer surgical site occurrences (0 vs. 8, p = 0.004). The total direct costs for rIPOM and eTEP were comparable [$8282 (6979-11835) vs. $8680 (7550-10282), p = 0.52] as the cost savings for eTEP attributable to mesh use [$442 (434-485) vs. $69 (62-76), p = < 0.0001] were offset by increased expenses for operative time [$669 (579-861) vs. $1075 (787-1367), p < 0.0001] and use of more robotic equipment [$760 (615-933) vs. $946 (798-1203), p = 0.001]. CONCLUSION: The avoidance of fixation in a robotic eTEP repair did not reveal a benefit in postoperative pain to offset the shorter operative time and surgeon workload offered by rIPOM.

Application of the acquisition of data for outcomes and procedure transfer (ADOPT) method to a hands-on course for teaching extended-view totally extraperitoneal (eTEP) hernia repair to practicing surgeons.

BACKGROUND: After completion of training, practicing surgeons rely on hands-on courses to expand their procedure armamentarium and improve their surgical technique. However, such courses vary in standardized teaching methods. SAGES developed the Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program as a method of longitudinal instruction utilizing standardized teaching techniques, mentorship, and webinars to cover additional techniques. This study examines the adoption of learned techniques and participant confidence before and after an ADOPT course focused on extended-view totally extraperitoneal (eTEP) hernia repair. METHODS: A hands-on course focused on eTEP hernia repair was conducted with enrollment capped at 10 participants. Pre-course and post-course surveys at 3, 6, and 12 months determined implementation of the learned procedure, case volume, and confidence with eTEP skills. A 5-point Likert scale (1 = not confident at all to 5 = completely confident) assessed confidence levels. Survey responses were summarized using descriptive statistics. RESULTS: Of the 10 participants, 10 (100%) completed the pre-course survey, and 7 (70%) completed at least one post-course survey. Median age was 48.5 years (36,56) with a median of 16 years (2,23) in practice, mostly in the community setting (70%). After the course, 50% had performed an eTEP procedure, and 100% reported considering this technique during surgical planning. Participants reported higher confidence in eTEP-specific skills at three months post-course from pre-course levels. The highest change in confidence was seen for the following skills: accessing the retromuscular/extraperitoneal space for ventral hernia and recognizing when the linea alba has been violated, p < 0.05. CONCLUSION: This study shows that rapid incorporation of learned techniques can be achieved through the ADOPT format. Furthermore, through longitudinal mentorship and a structured hands-on course, the ADOPT course supports practicing surgeons to attain autonomy and confidence even when teaching a relatively technically challenging procedure, such as eTEP.

eTEP-RS for incisional hernias in a non-robotic center. Is laparoscopy enough to perform a durable MIS repair of the abdominal wall defect?

INTRODUCTION: Incisional hernias can complicate up to 25% of laparotomies, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced. The method was presented relatively recently and continues to evolve. The use of a robotic platform in eTEP-RS resulted in a significant improvement in ergonomics. Therefore, the questions arise as to whether the laparoscopic technique might still be feasible for such long procedures. The objective of this study is to present our early results in the treatment of patients with incisional ventral hernias using eTEP-RS and to discuss key technical aspects. PATIENTS AND METHODS: A prospective case-controlled study was conducted for all incisional ventral hernia patients (hernia orifice between 4 and 10 cm) who underwent eTEP-RS between March 2019 and December 2021. Demographic data were recorded; and perioperative and postoperative results were analyzed. RESULTS: We performed 34 eTEP-RS procedures. The mean duration of the surgery was 211 min (145-295). The mean width of the defect was 6.8 cm and the defect area was 42.5 cm2. The mean mesh size was 498 cm2 (270-625). After an average follow-up of 16 months (2-30), there was no recurrence or major complication. CONCLUSIONS: The eTEP-RS is a safe alternative to open ventral hernia repair in selected cases and allows for the placement of a large piece of mesh in accordance with current recommendations, even in non-robotic centers. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair. Compliance with certain rules of the laparoscopic eTEP-RS facilitates improved ergonomics for this procedure even in non-robotic centers.

Learning curves of robotic extended totally extraperitoneal (eTEP) hernia repair among two surgeons at a high-volume community hospital: a cumulative sum analysis.

INTRODUCTION: Robotic extended totally extraperitoneal hernia (eTEP) repair is a novel technique for minimally invasive ventral hernia repair with retromuscular placement of mesh. This study aimed to evaluate the learning curve for robotic eTEP hernia repair using risk-adjusted cumulative sum (RA-CUSUM) analysis for two general surgeons-one with dedicated fellowship training in robotic eTEP technique (surgeon 2) and another without robotic eTEP-specific training (surgeon 1). METHODS: We conducted a retrospective analysis of 98 patients undergoing robotic eTEP hernia repair from July 2020 to February 2022 for two surgeons. RA-CUSUM method was applied to the overall operative time (OT) in minutes, adjusting for transversus abdominis release (TAR). RESULTS: Figures 3 (surgeon 1) and 4 (surgeon 2) illustrate the three phases in the RA-CUSUM graphs of OT. For surgeon 1, the cases for each phase were determined: phase 1 (1 to 12), phase 2 (13 to 24), and phase 3 (25 to 51). For surgeon 2, the three phases were similarly determined as 1 to 8, 9 to 32, and 33 to 47, respectively. A significant (p = 0.017) difference existed for the OTs between phases 1 (262 ± 69) and 3 (192 ± 63.0) for surgeon 1. OT compared to the risk-adjusted value stabilized after case 12 and decreased after case 24 for surgeon 1; it began to decrease after case 8 for surgeon 2. CONCLUSIONS: The initial learning curve for surgeon 1 reached its plateau after 12 cases, shorter than comparable studies. This was likely due to the surgeon's intentional focus on learning this technique through courses, proctoring, and active mentorship. The flat learning curve seen in surgeon 2's series illustrates the value of experience gained during fellowship training. Our data support that, given the right resources and support, a short learning curve for eTEP is attainable for community surgeons without prior training in the technique.

Comparison of outcomes of the extended-view totally extraperitoneal rives-stoppa (eTEP-RS) and the intraperitoneal onlay mesh with defect closure (IPOM-plus) for W1-W2 midline incisional hernia repair-a single-center experience.

BACKGROUND: The eTEP technique is a new approach that has recently gained popularity in abdominal wall hernia surgery. This study aimed to compare the outcomes of the eTEP-RS and IPOM-plus procedures in W1 and W2 midline incisional abdominal wall hernia (IAWH) repairs performed by the same surgeon. METHODS: Prospectively collected data of laparoscopic abdominal wall repairs performed on 61 patients with eTEP between November 2018 and April 2022 and on 67 patients with IPOM-plus between January 2016 and April 2022 were retrospectively analyzed. A total of 74 out of 128 patients, 30 in the eTEP-RS group and 44 in the IPOM-plus group, who underwent W1-W2 midline incisional hernia repair were included in the study. The mean follow-up was 24 months in the eTEP-RS group and 45 months in the IPOM-plus group. RESULTS: There was no statistically significant difference between the groups regarding age, sex, BMI, ASA score, or active smoking. No difference was seen between the two groups in terms of the mean defect area (MDA, 28.17 cm2 vs. 27.41 cm2, p = 0.84), but the mean mesh area (MMA) and mesh/defect (M/D) ratio were higher in the eTEP-RS group (404.11 cm2 vs. 267.85 cm2, p < 0.001 and 20.96 vs. 12.36, p = 0.004). In the eTEP-RS group, the hospital length of stay (LOS) (1.48 days vs. 2.58 days, p < 0.001) and pain on the first and 10th postoperative days were significantly lower (p < 0.001), while the operative time was significantly longer (204.07 min vs. 88.33 min, p < 0.001). There was no significant difference in terms of intraoperative complications (p = 0.56), seroma formation (p = 0.83), or recurrence (p = 0.83). CONCLUSION: The eTEP-RS technique has advantages over the IPOM-plus approach, such as a shorter LOS and less early postoperative pain with W1-W2 midline IAWH repair. However, the eTEP technique has a longer operative time.

Pitfalls and complications of enhanced-view totally extraperitoneal approach to abdominal wall reconstruction.

BACKGROUND: The enhanced-view totally extraperitoneal access technique (eTEP) to minimally invasive retromuscular abdominal wall reconstruction is a relatively novel technique that has continued to gain popularity. There is a paucity of information regarding the prevention and management of eTEP complications. We reviewed the literature to evaluate the complications reported with eTEP ventral hernia repair and discuss the main complications associated with this technique. METHODS: A literature search via PubMed was performed focusing on eTEP ventral hernia repair. Based on the available literature and own practice experience, the authors discuss key strategies for preventing and managing complications associated with the eTEP approach. RESULTS: One hundred fifty studies were identified. Forty-seven studies were fully reviewed and twenty-four were included in this review. The technical details of the technique were described as performed by the authors. Postoperative complications were classified into different categories and discussed separately. CONCLUSION: As the eTEP approach continues to gain popularity, it is essential to consider its unique complications. A focus on prevention with anatomical bearings and sound surgical technique is paramount.

Robotic-assisted repair of incisional hernia-early experiences of a university robotic hernia program and comparison with open and minimally invasive sublay technique (eMILOS).

PURPOSE: With robotic surgical devices, an innovative tool has stepped into the arena of minimally invasive hernia surgery. It combines the advantages of open (low recurrence rates and ability to perform complex procedure such as transverse abdominis release) and laparoscopic surgery (low rate of wound and mesh infections, less pain). However, a superiority to standard minimally invasive procedures has not yet been proven. We present our first experiences of robotic mesh repair of incisional hernias and a comparison of our results with open and minimally invasive sublay techniques. METHODS: A retrospective analysis of all patients who underwent robotic-assisted mesh repair (RAHR) for incisional hernia between April and November 2022 (RAHR group) and patients who underwent open sublay (Sublay group) or eMILOS hernia repair (eMILOS group) between January 2018 and November 2022 was carried out. Patients in the RAHR group were matched 1:2 to patients in the Sublay group by propensity score matching. Patient demographics, preoperative hernia characteristics and cause of hernia, intraoperative variables, and postoperative outcomes were evaluated. Furthermore, a subgroup analysis of only midline hernia was performed. RESULTS: A total of 21 patients received robotic-assisted incisional hernia repair. Procedures performed included robotic retro-muscular hernia repair (r-RMHR, 76%), with transverse abdominis release in 56% of the cases. In one patient, r-RHMR was combined with robotic inguinal hernia repair. Two patients (10%) were operated with total extraperitoneal technique (eTEP). Robotic-assisted transabdominal preperitoneal hernia repair (r-TAPP) was performed in three patients (14%). Median (range) operating time in the RAHR group was significantly longer than in the sublay and eMILOS group (291 (122-311) vs. 109.5 (48-270) min vs. 123 (100-192) min, respectively, p < 0.001). The meshes applied in the RAHR group were significantly compared to the sublay (mean (SD) 529 ± 311 cm2 vs. 356 ± 231, p = 0.037), but without a difference compared to the eMILOS group (mean (SD) 596 ± 266 cm2). Median (range) length of hospital stay in the RAHR group was significantly shorter compared to the Sublay group (3 (2-7) vs. 5 (1-9) days, p = 0.032), but not significantly different to the eMILOS group. In short term follow-up, no hernia recurrence was observed in the RAHR and eMILOS group, with 9% in the Sublay group. The subgroup analysis of midline hernia revealed very similar results. CONCLUSION: Our data show a promising outcome after robotic-assisted incisional hernia repair, but no superiority compared to the eMILOS technique. However, RAHR is a promising technique especially for complex hernia in patients with relevant risk factors, especially immunosuppression. Longer follow-up times are needed to accurately assess recurrence rates, and large prospective trials are needed to show superiority of robotic compared to standard open and minimally invasive hernia repair.

Efficacy of extended view totally extra peritoneal approach versus laparoscopic intraperitoneal on lay mesh plus for abdominal wall hernias: a single center preliminary retrospective study.

BACKGROUND: Laparoscopic minimally invasive surgery has become the primary treatment for ventral hernias. The laparoscopic intraperitoneal on lay mesh (IPOM) plus approach for abdominal wall hernias is the most used procedure, while extended view totally extraperitoneal (e­TEP) repair is a newer option. This study aimed to compare the effectiveness and complications of the 2 procedures for abdominal wall hernias repair. METHODS: This was a retrospective and comparative single-center study done at The Second Clinical Medical College, Jinan University Hospital (Shenzhen People's Hospital), Shenzhen, China. The study included patients with a 2 to 6 cm abdominal wall defect who underwent hernia repair from January 2022 to December 2022. Patients' baseline characteristics, hernia features, operative time, blood loss, postoperative pain level, and total hospitalization expenses were extracted from the medical records and compared between patients who underwent the IPOM plus and e-TEP repair. RESULTS: A total of 53 patients were included: 22 in the e-TEP group and 31 in IPOM plus group. Patient demographic characteristics were similar between the 2 groups. The operation time of the e-TEP groups was significantly longer than the IPOM plus (98.5 ± 10.7 min vs. 65.9 ± 7.3 min, P < 0.01). Postoperative pain levels (VAS; visual analog scale) (4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements (Tramadol) (25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay (1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and total hospitalization expenses (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01) were significantly lower in the e-TEP group. The mean intraoperative blood loss was similar between the 2 groups. No postoperative complications were observed in either group. CONCLUSION: The e-TEP approach for abdominal wall hernias appears to be better than IPOM plus with respect to postoperative pain levels(VAS: 4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements(25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay(1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and hospitalization costs (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01).

Abdominal Wall Reconstruction Performing Posterior Component Separation without Transversus Abdominis Release, for a Complex Incisional Hernia (M2W1, L3W2 left) after TRAM Flap Breast Reconstruction (with video).

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/Diana_Teodora_Cucu-Abdominal_Wall_Reconstruction.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/Diana_Teodora_Cucu-Abdominal_Wall_Reconstruction.mp4" type="video/mp4" Your browser does not support the video tag. /video Breast reconstruction with a pedicled transverse rectus abdominis muscle (TRAM) flap can result in significant abdominal wall donor-site morbidity. Although the pedicled TRAM flap donor area reinforced with mesh results in decreased rates of postoperative abdominal bulging and hernias, the best technique to accomplish that is yet to be elucidated. Antonio Espinosa de Los Monteros all. published recently a novel technique of posterior components separation with transversus abdominis muscle release and retro-muscular mesh reinforcement for donor-area closure during pedicled TRAM flap breast reconstruction (1). In this case we present this technique using the robotic technology. The robotic surgery allows a delicate dissection of the pre-peritoneal and pre-transversalis space, which represents a posterior component separation without transversus abdominis release (TAR). It is about a 40 y.o. lady, BMI 25 who underwent a radical mastectomy and TRAM flap breast reconstruction. She developed a complex incisional hernia, M2W1 and L3W2 on the left flank, considering the EHS classification (2). Our robotic approach is a minimally invasive surgery (MIS), enhanced view totally extraperitoneal (eTEP)(3) access technique which respects and follows the principles of the original open technique. The key-stages of the procedure are: 1. development of the retro-rectus space, using an optic trocar; 2. placement of the ports, medially to the linea semilunaris; 3. crossingover the midline; 4. dissection the contra-lateral pre-peritoneal/pre-transversalis space (without trans-section of the transversus abdominis muscle); 5. closure of the lateral defect and then, restoration of linea alba; 6. mesh placement. Combining the eTEP approach together with the posterior component separation (but avoiding TAR) and also with the benefits of the robotic surgery, this technique offers a fast recovery and excellent cosmetic results.

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial.

BACKGROUND: There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life. METHOD: This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes. RESULTS: Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective. CONCLUSION: eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.

The extended-view totally extraperitoneal (eTEP) approach for incisional abdominal wall hernias: results from a single center.

BACKGROUND: The extended-view totally extraperitoneal (eTEP) approach is a promising technique for abdominal wall hernias and has increased in popularity among hernia surgeons in recent years. This study aims to present the results of applying the laparoscopic eTEP approach for incisional abdominal wall hernias (IAWHs). METHODS: This study is a retrospective analysis of a prospectively collected dataset of 30 patients who underwent laparoscopic eTEP for IAWHs between October 2018 and March 2021 (median follow-up of 15 months). RESULTS: Thirty patients (8 male, 22 female) with a mean age, mean body mass index, and median ASA score of 53.5, 30.8, and 2, respectively, underwent the eTEP procedure for incisional abdominal wall hernias. In total, 11 (36.7%) patients had a recurrent IAWH. Seventeen (56.7%) patients were treated with eTEP RivesStoppa (eTEP-RS), whereas 10 (33.3%) patients needed the eTEP transversus abdominis release (eTEP-TAR) procedure. In three patients, conversions to other procedures (laparoscopic intraperitoneal onlay mesh-plus (IPOM-Plus) and open RivesStoppa) were needed due to intraoperative complications: iatrogenic perforation to the intestine and large peritoneal tear causing loss of the working space. The mean operative time and mean length of stay (LOS) were 203.5 min and 1.5 days for eTEP-RS and 291.5 min and 1.6 days for eTEP-TAR, respectively. Two patients developed asymptomatic seromas, and one patient developed an asymptomatic hematoma; all were treated conservatively. Only one recurrence was observed over the course of the follow-up period. CONCLUSIONS: The eTEP approach is a safe and feasible option for IAWH repair and a valuable addition to the armamentarium of hernia surgeons.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results.

INTRODUCTION: Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation. AIM: To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach. METHODS: A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported. RESULTS: 66 patients were included in the study. Median follow-up was 22 months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12 years, 30 kg/m2, 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9 cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%). CONCLUSION: eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.

Are drains useful in eTEP ventral hernia repairs? An AWR surgical collaborative (AWRSC) retrospective study.

BACKGROUND: Drain practices in minimally invasive retromuscular ventral hernia repairs have largely been transferred over from open surgery without significant review. We wished to evaluate the role of drains in these repairs. METHODS: Using the Abdominal Wall Reconstruction Surgical Collaborative (AWRSC) registry, patients with ventral hernias who underwent enhanced-view totally extraperitoneal (eTEP) repairs between February 2016 and September 2019 were evaluated. Patients with contamination or active infection within the surgical field, those who underwent an emergent or hybrid repair, or received a concomitant procedure were excluded. Propensity score matching based on the defect size, previous hernia repair status, and the use of posterior component separation (PCS) was used to match patients with drains to patients without drains. We evaluated 180-day outcomes in terms of SSIs, SSOs, and recurrence. RESULTS: 308 patients met the inclusion criteria. After propensity score matching, 48 patients with drains and 72 without drains were included in the analysis cohort. Those with drains were older with a greater likelihood of an incisional hernia, but were broadly similar for other relevant demographic and hernia-related variables. While there was no difference in the incidence of SSOs and SSIs between the two groups, we report a higher risk of SSOs needing procedural intervention (SSOPI) and recurrence, with a lengthened hospital stay in the cohort that received surgical drains. CONCLUSION: The use of surgical drains in "clean" eTEP repairs of ventral hernias appears to be common, with a selection bias for more complex cases. Based on our analysis, we found the use of drains was associated with longer hospital stays. The use of drains did not change the likelihood of suffering an SSI or SSO. However, the incidence of SSOPIs was higher despite the use of drains, which raises questions about their protective role in these repairs.

The current state of robotic retromuscular repairs-a qualitative review of the literature.

BACKGROUND: The management of ventral incisional hernias (VIH) has undergone many iterations over the last 5 years due to evolution in surgical techniques and advancement in robotic surgery. Four general principles have emerged: mesh usage, retromuscular mesh placement, primary fascial closure, and usage of minimally invasive techniques when possible. The application of robotic retromuscular repairs in VIH allow these principles to be applied simultaneously. This qualitative review attempts to answer what robotic retromuscular repairs are described, which patients are selected for these techniques, and what are current outcomes. METHODS: Using the key words: "robotic retromuscular repair", "robotic Rives Stoppa", and "robotic transversus abdominis release", a PubMed search of articles written up to December 2019 was critically reviewed. RESULTS: 44 articles were encountered, 9 high-quality articles were analyzed for this manuscript. Level of evidence ranged from 2B to 2C. Robotic TAR patients had BMI of 33 kg/m2, defect sizes ranging from 7-14 cm wide to 12-19 cm long, longer OR times, no difference in surgical site events, and shorter length of stay (LOS). The techniques to perform robotic Rives Stoppa (RS) were heterogeneous; however, extended totally extraperitoneal (ETEP) approach is most described. Defect width for RS repairs ranged 4-7 cm and LOS was less than 1 day. Complication rates were low, there is no long-term data on hernia recurrence, and information on cost is limited. CONCLUSION: In short-term follow-up, robotic retromuscular repairs show promise that VIH can be repaired with intramuscular mesh, few complications, and shorter LOS. Data on hernia recurrence, long-term complications, and rigorous cost analysis are needed to demonstrate generalizability.