Cost analysis of open versus robot-assisted ventral hernia repair - a retrospective cohort study.

BACKGROUND: Robot-assisted ventral hernia repair is associated with decreased length of stay and lower complication rates compared with open repair, but acquisition and maintenance of the robotic system is costly. The aim of this was study was to compare the procedure-specific cost of robot-assisted and open ventral and incisional hernia repair including cost of procedure-related readmissions and reoperations within 90 days postoperatively. METHODS: Single-center retrospective cohort study of 100 patients undergoing robot-assisted ventral hernia. Patients were propensity-score matched 1:1 with 100 patients undergoing open repairs on age, type of hernia (primary/incisional), and horizontal defect size. The primary outcome of the study was the total cost per procedure in Euros including the cost of a robotic approach, extra ports, mesh, tackers, length of stay, length of readmission, and operative reintervention. The cost of the robot itself was not included in the cost calculation. RESULTS: The mean length of stay was 0.3 days for patients undergoing robot-assisted ventral hernia repair, which was significantly shorter compared with 2.1 days for patients undergoing open repair, P < 0.005. The readmission rate was 4% for patients undergoing robot-assisted ventral hernia repairs and was significantly lower compared with open repairs (17%), P = 0.006. The mean total cost of all robot-assisted ventral and incisional hernia repairs was 1,094 euro compared with 1,483 euro for open repairs, P = 0.123. The total cost of a robot-assisted incisional hernia repair was significantly lower (1,134 euros) compared with open ventral hernia repair (2,169 euros), P = 0.005. CONCLUSIONS: In a Danish cohort of patients with incisional hernia, robot-assisted incisional hernia repair was more cost-effective than an open repair due to shortened length of stay, and lower rates of readmission and reintervention within 90 days.

Systematic review and meta-analysis comparing surgical site infection in abdominal surgery between triclosan-coated and uncoated sutures.

PURPOSE: Surgical site infection (SSI) is a frequent complication after abdominal surgery and impacts morbidity, mortality and medical costs. This systematic review evaluates whether the use of triclosan-coated sutures for closing the fascia during abdominal surgery reduces the rate of SSI compared to uncoated sutures. METHODS: A systematic review and meta-analysis were conducted using the PRISMA guidelines. On February 17, 2024, a literature search was performed in Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Embase. Randomized controlled trials (RCTs) on abdominal fascial closure in human adults, comparing triclosan-coated and uncoated sutures, were included. The risk of bias was assessed using the Cochrane RoB 2 tool. Pooled meta-analysis was performed using RevMan. RESULTS: Out of 1523 records, eleven RCTs were included, with a total of 10,234 patients: 5159 in the triclosan-coated group and 5075 in the uncoated group. The incidence of SSI was statistically significantly lower in the triclosan-coated group (14.8% vs. 17.3%) with an odds ratio (OR) of 0.84 (95% CI [0.75, 0.93], p = 0.001). When polydioxanone was evaluated separately (coated N = 3999, uncoated N = 3900), triclosan-coating reduced SSI; 17.5% vs. 20.1%, OR 0.86 (95% CI [0.77; 0.96], p = 0.008). When polyglactin 910 was evaluated (coated N = 1160, uncoated N = 1175), triclosan-coating reduced the incidence of SSI; 5.4% vs. 7.8%, OR 0.67 (95% CI [0.48; 0.94], p = 0.02). CONCLUSION: According to the results of this meta-analysis the use of triclosan-coated sutures for fascial closure statistically significantly reduces the incidence of SSI after abdominal surgery with a risk difference of about 2%.

Certified Fellowship in Abdominal Wall Surgery-A Collaboration Between the UEMS and the European Hernia Society.

Background: Abdominal wall surgery (AWS) is characterised by the increasing caseload and the complexity of the surgical procedures. The introduction of a tailored approach to AWS utilising laparoendoscopic, robotic and/or open techniques requires the surgeon to master several surgical techniques. All of which have an associated learning curve, and the necessary knowledge/experience to know which operation is the right one for the individual patient. However, the reality in general surgery training shows that training in just a limited number of procedures is not enough. By the end of general surgery training, many chief residents do not feel they are yet ready to carry out surgery independently. Therefore, hernia surgery experts and societies have called for the introduction of a Fellowship in Abdominal Wall Surgery. Methods: The UEMS (Union Européenne des Médecins Spécialistes, European Union of Medical Specialists) in collaboration with the European Hernia Society (EHS) introduced a fellowship by examination in 2019. As a prerequisite, candidates must complete further training of at least 2 years with a special focus on abdominal wall surgery after having completed their training in general surgery. To be eligible for the examination, candidates must provide evidence of having performed 300 hernia procedures. In addition, candidates must have accrued sufficient "knowledge points" by attending abdominal wall surgery congresses, courses and clinical visitations, and engaged in scientific activities. On meeting the requirements, a candidate may be admitted to the written and oral examination. Results: To date, three examinations have been held on the occasion of the Annual Congress of the European Hernia Society in Copenhagen (2021), Manchester (2022) and Barcelona (2023). Having met the requirements, 48 surgeons passed the written and oral examination and were awarded the Fellow European Board of Surgery-Abdominal Wall Surgery certificate. During this time period, a further 25 surgeons applied to sit the examination but did not fulfil all the criteria to be eligible for the examination. Fifty experienced abdominal wall surgeons applied to become an Honorary Fellow European Board of Surgery-Abdominal Wall Surgery. Fourty eight were successful in their application. Conclusion: The Fellowship of the European Board of Surgery - Abdominal Wall Surgery by examination has been successfully introduced at European level by the joint work of the UEMS and the EHS. The examination is also open to surgeons who work outside the European area, if they can fulfil the eligibility criteria.

PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study).

Background: Negative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life. Method: This is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life. Conclusion: Patients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Short-term Outcomes After Laparoscopic IPOM Versus Robot-assisted Retromuscular Repair of Small to Medium Ventral Hernias: A Nationwide Database Study.

OBJECTIVE: To examine the short-term outcomes after laparoscopic intraperitoneal onlay mesh (IPOM) compared with robot-assisted retromuscular repair of small to medium-sized ventral hernia. BACKGROUND: With the introduction of a robot-assisted approach, retromuscular mesh placement is technically more feasible compared with laparoscopic IPOM, with potential gains for the patient, including avoidance of painful mesh fixation and intraperitoneal mesh placement. METHODS: This was a nationwide cohort study of patients undergoing either laparoscopic IPOM or robot-assisted retromuscular repair of a ventral hernia with a horizontal fascial defect <7 cm in the period 2017 to 2022, matched in a 1:2 ratio using propensity scores. Outcomes included postoperative hospital length of stay, 90-day readmission, and 90-day operative reintervention, and multivariable logistic regression analysis was performed to adjust for the relevant confounder. RESULTS: A total of 1136 patients were included for analysis. The rate of IPOM-repaired patients hospitalized > 2 days was more than 3 times higher than after robotic retromuscular repair (17.3% vs. 4.5%, P < 0.001). The incidence of readmission within 90 days postoperatively was significantly higher after laparoscopic IPOM repair (11.6% vs. 6.7%, P =0.011). There was no difference in the incidence of patients undergoing operative intervention within the first 90 days postoperatively (laparoscopic IPOM 1.9% vs. robot-assisted retromuscular 1.3%, P =0.624). CONCLUSIONS: For patients undergoing first-time repair of a ventral hernia, robot-assisted retromuscular repair was associated with a significantly reduced incidence of prolonged length of postoperative hospital stay and risk of 90-day readmission compared to laparoscopic IPOM.

Trends in Use of Laparoscopic Intraperitoneal Onlay Mesh for Ventral Hernia Repair.

This cohort study examines changes in the proportion of laparoscopic intraperitoneal onlay mesh procedures performed for hernia repair in Denmark since initial description of the procedure.

Update of the international HerniaSurge guidelines for groin hernia management.

BACKGROUND: Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. METHOD: A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. RESULTS: Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. CONCLUSION: The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities-A Nationwide Cohort Study.

INTRODUCTION: Umbilical hernia is a frequent condition in patients with cirrhosis. The aim of the study was to evaluate the risks associated with umbilical hernia repair in patients with cirrhosis in the elective and emergency setting. Secondly, to compare patients with cirrhosis with a population of patients with equally severe comorbidities but without cirrhosis. METHODS: Patients with cirrhosis who underwent umbilical hernia repair from January 1, 2007, to December 31, 2018, were included from the Danish Hernia Database. A control group of patients with a similar Charlson score (≥ 3) without cirrhosis was generated using propensity score matching. The primary outcome was postoperative re-intervention within 30 days following hernia repair. Secondary outcomes were mortality within 90 days and readmission within 30 days following hernia repair. RESULTS: A total of 252 patients with cirrhosis and 504 controls were included. Emergency repair in patients with cirrhosis was associated with a significantly increased rate of re-intervention (54/108 (50%) vs. 24/144 (16.7%), P < 0.001), 30-day readmission rate (50/108 (46.3%) compared with elective repair vs. 36/144 (25%) (P < 0.0001)), and 90-day mortality (18/108 (16.7%) vs. 5/144 (3.5%), P < 0.001). Patients with cirrhosis were more likely to undergo a postoperative re-intervention compared with comorbid patients without cirrhosis (OR = 2.10; 95% CI [1.45-3.03]). CONCLUSION: Patients with cirrhosis and other severe comorbidity undergo emergency umbilical hernia repair frequently. Emergency repair is associated with increased risk of poor outcome. Patients with cirrhosis undergo a postoperative reintervention more frequently than patients with other severe comorbidity undergoing umbilical hernia repair.

Outcomes After Spigelian Hernia Repair: A Nationwide Database Study.

BACKGROUND: Spigelian hernia is a rare hernia of the abdominal wall. Due to lack of evidence, there is no standard recommendation for surgical technique of Spigelian hernia repair. The aim of this study was to evaluate the outcomes after open and laparoscopic, elective and emergency repair of Spigelian hernias on a nationwide basis. METHODS: Nationwide data from the Danish Ventral Hernia Database and the National Patient Registry was assessed to analyze outcomes after Spigelian hernia repair. A total of 365 patients were operated for Spigelian hernia in Denmark from 2007 to 2018. Ninety-day readmission, 90-day reoperation and long-term operation for recurrence were evaluated, as well as possible differences between open and laparoscopic, and elective and emergency repairs. RESULTS: Most of the patients (80.5%, 294/365) were operated by laparoscopic approach and 19.5% (71/365) were operated by open approach. Elective surgery was performed in 83.6% (305/365) of the patients and 16.4% (60/365) underwent emergency repair. There were no significant differences in 90-day readmission or reoperation rates between open or laparoscopic Spigelian hernia repairs, P = 0.778 and P = 0.531. Ninety-day readmission and 90-day reoperation rates were also comparable for elective versus emergency repair, P = 0.399 and P = 0.766. No difference was found in operation for recurrence rates between elective and emergency, nor open and laparoscopic Spigelian hernia repairs. CONCLUSIONS: This study demonstrates that 16% of Spigelian hernia repairs are done in the emergency setting. Open and laparoscopic approach are comparable in terms of early readmission, reoperation, and recurrence rates.

Treatment of postgestational rectus diastasis.

Rectus diastasis is defined by thinning and widening of linea alba and is a part of pregnancy. In some patients, the diastasis persists giving symptoms such as core instability, and cosmetic complaints. Treatment consists of exercise and surgery by either a plastic surgeon or a general surgeon. Lately, rectus diastasis has gained both national and international attention but it is not clear which patients will benefit from surgery or which operative technique has the best outcome. This review describes postgestational rectus diastasis and summarizes treatment possibilities based on the latest literature.

Treatment of incisional and parastomal hernias in Denmark.

Incisional and parastomal hernias are frequent complications after abdominal surgery. Patients with relevant symptoms should be referred to the local surgical department for diagnosis and indication for surgery. Patients with giant and parastomal hernias are referred to one of the five Danish regional hernia centres. Patients with parastomal hernias often benefit from being referred to a stoma nurse. The most frequent complications after hernia repair are wound complications and recurrence. In case of severe wound infection, incarceration, or strangulation the patient must always be referred acutely, as argued in this review.

Outcomes of parastomal hernia repair after national centralization.

BACKGROUND: In 2010, it was decided to centralize parastomal hernia repairs to five specialized hernia centres in Denmark to improve outcomes. The aim of this nationwide cohort study was to evaluate whether centralization of parastomal hernia repairs has had an impact on outcomes. Specifically, readmission, reoperation for complication, and operation for recurrence were analysed before and after centralization. METHODS: By merging clinical and administrative outcome data from the Danish Hernia Database with those from the Danish National Patient Registry, all patients undergoing parastomal hernia repair in Denmark from 1 January 2007 to 31 December 2018 were included. Centralization was defined as having at least 70 per cent of procedures were performed at one of the five national centres. Readmission, reoperation, and recurrence rates for emergency and elective repairs were evaluated before and after centralization. RESULTS: In total, 1062 patients were included. Median follow-up was 992 days. Overall, the centralization process took 7 years. For elective repairs, the readmission, reoperation, mortality, and recurrence rates were comparable before and after centralization, but more patients overall and more patients with co-morbidity were offered surgery after centralization. For emergency repairs, there was a significant reduction in rates of reoperation (from 44.9 per cent (48 of 107) to 23 per cent (14 of 62); P = 0.004) and mortality (from 10.3 per cent (11 of 107) to 2 per cent (1 of 62); P = 0.034) after centralization. CONCLUSION: Centralization led to more elective operations and better outcomes when emergency repair was needed. Centralization of parastomal hernia repair led to more patients receiving elective repair and significantly improved outcomes after emergency repair.

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.

[The treatment of umbilical hernia in patients with cirrhosis].

Patients with cirrhosis undergoing emergency umbilical hernia repair have increased risk of fatal complications. Of all patients with cirrhosis and umbilical hernia, 43% undergo emergency hernia repair, and thus the feasibility of elective procedures in this patient group was examined. This review found that medical and wound-related complications were the most frequent after umbilical hernia repair in patients with cirrhosis. Accordingly, additional evidence is needed to evaluate methods allowing for elective umbilical hernia repair in patients with cirrhosis.

Suture or Mesh Repair of the Smallest Umbilical Hernias: A Nationwide Database Study.

BACKGROUND: Mesh is recommended for umbilical hernias with defects > 1 cm to reduce recurrence. For umbilical hernias with defect width ≤ 1 cm, the literature is sparse. The aim of this nationwide cohort study was to assess outcomes after suture and mesh repair of umbilical hernias with defect width ≤ 1 cm and to evaluate outcomes after onlay mesh repair specifically. METHODS: By merging data from the Danish Hernia Database and the National Patients Registry from 2007 to 2018, patients undergoing elective open repair of an umbilical hernia with defect width ≤ 1 cm were identified. Available data included details about comorbidity, surgical technique, 90-day readmission, 90-day reoperation and operation for recurrence. RESULTS: A total of 7849 patients were included, of whom 25.7% (2013/7849) underwent mesh repair. Reoperation for recurrence was significantly decreased after mesh repair 3.1% (95% C.I. 2.1-4.1) compared with suture repair 6.7% (95% C.I. 6.0-7.4), P < 0.001. Readmission and reoperation rates were significantly higher for mesh repair 7.9% (159/2013) and 2.6% (52/2013) than for suture repair 6.5% (381/5836) and 1.5% (89/5836), P = 0.036 and P = 0.002, respectively. Onlay mesh repairs had the lowest risk of recurrence 2.0% (95% C.I. 0.6-3.5), and readmission [7.9% (65/826)] and reoperation [3.9% (32/826)] rates within 90 days were comparable to suture repairs [6.5% (381/5836)] and [3.3% (192/5836)], P = 0.149 and P = 0.382, respectively. CONCLUSIONS: Even for the smallest umbilical hernias, mesh repair significantly decreased the recurrence rate. Onlay mesh repair was associated with lowest risk of recurrence without increasing early complications.

Perioperative clinical management in relation to emergency surgery for perforated peptic ulcer: A nationwide questionnaire survey.

BACKGROUND & AIMS: Perforation is a severe complication of peptic ulcer disease. Evidence regarding perioperative management of patients undergoing surgery for perforated peptic ulcer is scarce without any clear guidelines. This study aimed to investigate the clinical practice and possible differences in the perioperative management of patients undergoing emergency surgery for perforated peptic ulcers in Denmark. METHODS: The study was an anonymous, nationwide questionnaire survey. All doctors working at general surgical departments in Denmark were included. The questionnaire consisted of four parts; 1) demographic details including job position, subspecialty, geographic location, and surgical experience, 2) pre- and postoperative use of nasoenteral tubes, 3) routine use of nil-by-mouth (NBM) regime, 4) questions regarding postoperative nutrition.Subgroup analyses were performed according to job position and subspecialty. RESULTS: In total, the questionnaire was answered by 287 surgeons, of which 74% were experienced surgeons being able to perform surgery for perforated peptic ulcers independently.Pre- and postoperative nasoenteral tubes were used routinely by the majority of the respondents. One of five surgeons routinely practiced a postoperative NBM regime. Generally, the respondents allowed clear fluids postoperatively without restrictions but were reluctant to allow free fluids or solid foods. Two of three surgeons routinely used tube- or parental nutrition. The results varied depending on job position and subspecialty. CONCLUSIONS: After emergency surgery, the postoperative management of patients with perforated peptic ulcers varies considerably among general surgeons in Denmark. Evidence-based national or international guidelines are needed to standardize and optimize the clinical practice.