The current application and evidence for robotic approach in abdominal surgery: A narrative literature review.

The current application of robotic surgery is evolving at a high pace in the current years. The technical advantages enable several abdominal surgical procedures to be performed minimally invasive instead of open surgery. Furthermore, procedures previously performed successfully using standard laparoscopy are now performed with a robotic approach, with conflicting results. The present narrative review reports the current literature on the robotic surgical procedures typically performed in a typical Scandinavian surgical department: colorectal, hernia, hepato-biliary, and esophagogastric surgery.

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.

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.

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.

EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention-With ESCP and EAES Participation.

Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.

Update Systematic Review, Meta-Analysis and GRADE Assessment of the Evidence on Parastomal Hernia Prevention-A EHS, ESCP and EAES Collaborative Project.

Objective: To perform a systematic review and meta-analysis on the effectiveness of prophylactic mesh for the prevention of parastomal hernia in end colostomy, with the ultimate objective to summarize the evidence for an interdisciplinary, European rapid guideline. Methods: We updated a previous systematic review with de novo evidence search of PubMed from inception up to June 2022. Primary outcome was quality of life (QoL). Secondary outcomes were clinical diagnosis of parastomal hernia, surgery for parastomal hernia, and 30 day or in-hospital complications Clavien-Dindo ≥3. We utilised the revised Cochrane Tool for randomised trials (RoB 2 tool) for risk of bias assessment in the included studies. Minimally important differences were set a priori through voting of the panel members. We appraised the evidence using GRADE and we developed GRADE evidence tables. Results: We included 12 randomized trials. Meta-analysis suggested no difference in QoL between prophylactic mesh and no mesh for primary stoma construction (SMD = 0.03, 95% CI [-0.14 to 0.2], I2 = 0%, low certainty of evidence). With regard to parastomal hernia, the use of prophylactic synthetic mesh resulted in a significant risk reduction of the incidence of the event, according to data from all available randomized trials, irrespective of the follow-up period (OR = 0.33, 95% CI [0.18-0.62], I2 = 74%, moderate certainty of evidence). Sensitivity analyses according to follow-up period were in line with the primary analysis. Little to no difference in surgery for parastomal hernia was encountered after pooled analysis of 10 randomised trials (OR = 0.52, 95% CI [0.25-1.09], I2 = 14%). Finally, no significant difference was found in Clavien-Dindo grade 3 and 4 adverse events after surgery with or without the use of a prophylactic mesh (OR = 0.77, 95% CI [0.45-1.30], I2 = 0%, low certainty of evidence). Conclusion: Prophylactic synthetic mesh placement at the time of permanent end colostomy construction is likely associated with a reduced risk for parastomal hernia and may confer similar risk of peri-operative major morbidity compared to no mesh placement. There may be no difference in quality of life and surgical repair of parastomal hernia with the use of either approach.

[The application, rationale, and current evidence for arobotic approach in abdominal surgery].

High-level evidence now strongly supports the use of a minimally invasive approach in most abdominal surgical procedures. Minimally invasive surgery is performed with either a laparoscopic or a robotic approach, and the robotic approach has been implemented to overcome some of the inherent limitations of the conventional laparoscopic approach. In Denmark, robotic surgery is widely adopted, and this review describes the application and rationale of a robotic approach in different subspecialties, while also presenting the available high-level evidence.

[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.

Limited value of preoperative neutrophil-to-lymphocyte ratio to predict post-operative outcomes after major emergency abdominal surgery.

INTRODUCTION Major emergency abdominal surgery results in a high risk of morbidity and mortality. Preoperative neutrophil-to-lymphocyte ratio (NLR) has been proposed as a predictor of post-operative outcomes in elective surgery. The aim of the present study was to examine whether preoperative NLR was associated with post-operative morbidity and mortality after major emergency abdominal surgery. METHODS We conducted a retrospective cohort study of patients undergoing major emergency abdominal surgery in two university hospitals in Denmark between 2010 and 2016. Associations between preoperative NLR and 30-day post-operative complications and mortality were established through multivariate logistic regression and receiver-operating characteristics (ROC) analysis. RESULTS A total of 570 patients were included in the study. The overall 30-day mortality was 9.3% and 59.3% had post-operative complications. The median preoperative NLR was 8.6 (interquartile range: 4.8-14.7). Although NLR was higher in the group of patients who had complications or died after surgery, a multivariate analysis showed that the NLR was not associated with 30-day post-operative complications (odds ratio (OR) = 1.01 (95% confidence interval (CI): 0.99-1.02); p = 0.424) or mortality (OR = 0.99 (95% CI: 0.97-1.02); p = 0.57). The ROC analysis showed an area under the curve of 0.55 and 0.60 for 30-day post-operative complications and mortality, respectively. CONCLUSIONS Preoperative NLR was not associated with 30-day post-operative complications and mortality in patients undergoing major emergency abdominal surgery. FUNDING none. TRIAL REGISTRATION not relevant.

Stoma-site hernia after stoma reversal following rectal cancer resection.

INTRODUCTION: Stoma-site incisional hernia is a common complication. Besides decreasing affected patients' quality of life, it may lead to emergency surgery due to incarceration. If stoma sites lead to an incisional hernia analogous to other abdominal incisions, considerable underreporting may be present in the literature. METHODS: This was a single-centre, retrospective cohort study comprising consecutive patients undergoing laparoscopic rectal resection for rectal carcinoma with temporary diverting stoma and subsequent stoma reversal. CTs were reviewed to identify stoma-site incisional hernia, and potential confounders for development of a hernia were assessed. RESULTS: A total of 91 patients underwent stoma reversal and subsequent CT. In all, 72 of the 91 included patients had a transverse colostomy, among whom 19 (26%) developed a hernia. Among the remaining 19 patients treated with an ileostomy, four (21%) developed stoma-site incisional hernia. The mean time from stoma reversal to follow-up CT was 47.6 months (range: 28.5-66.7 months). No significant associations between stoma-site hernia and the included potential risk factors were observed. CONCLUSIONS: 25% developed reversal-site incisional hernia. We were unable to find any predictors for development of stoma reversal-site hernia. If hernias occur as frequently as this study shows, investigation of potential ways to decrease their occurrence is warranted. FUNDING: none. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency (R. no. 2012-58-0004).

Incidence of Incisional Hernia Repair After Laparoscopic Compared to Open Resection of Colonic Cancer: A Nationwide Analysis of 17,717 Patients.

BACKGROUND: It remains unknown whether laparoscopic compared to open surgery translates into fewer incisional hernia repairs (IHR). The objectives of the current study were to compare the long-term incidence of IHR and the size of repaired hernias between patients subjected to laparoscopic or open resection of colonic cancer. METHODS: This was a nationwide cohort study comprised of patients undergoing resection for colonic cancer between January 2007 and March 2016 according to the Danish Colorectal Cancer Group database. Patients who subsequently underwent IHR were identified in the Danish Ventral Hernia Database, from which information about the priority of the hernia repair and the size of the fascial defect was retrieved. RESULTS: The study included 17,717 patients, of whom 482 (2.7%) underwent subsequent IHR during a median follow-up of 4.7 (interquartile range 2.8-6.9) years. There was no significant difference in the 5-year cumulative incidence of hernia repair after laparoscopic compared to open colonic resection (3.9%, CI 3.3-4.4% vs 4.1%, CI 3.5-4.6%). After adjustment for confounders, laparoscopic approach was associated with an increased rate of emergency IHR (HR 2.37, 95% CI 1.03-5.46, P = 0.042) as opposed to elective IHR (HR 0.91, 95% CI 0.73-1.14, P = 0.442). Laparoscopic surgery was significantly associated with a decreased fascial defect area compared to open surgery (mean difference -16.0 cm2, 95% CI -29.4 to -2.5, P = 0.020). CONCLUSIONS: There was no difference in the incidence of IHR after open compared to laparoscopic resection. Compared to the open approach, laparoscopic resection increased the rate of subsequent emergency IHR, suggesting that a more aggressive therapeutic approach may be warranted in this patient group upon diagnosis of an incisional hernia.

Visceral obesity and short-term outcomes after laparoscopic rectal cancer resection.

BACKGROUND: Complications after rectal resection are frequent. Recently, methods to assess visceral obesity (VO) have become available as an alternative to measurement of body mass index (BMI). The aim of this study was to examine the association between visceral fat volume (VFV) and the short-term outcomes after laparoscopic low anterior resection (LLAR) in patients with rectal cancer. METHODS: We studied a consecutive series of patients undergoing LLAR at Bispebjerg University Hospital from 01.01.2013 to 01.01.2016. Preoperative VFV was calculated from abdominal CT scans using an automatic segmentation tool. The primary outcome was anastomotic leakage (AL). Secondary outcomes included conversion to open surgery, number of lymph nodes harvested, the rates of 30-day complications as well as reoperations, and 1-year survival. RESULTS: A total of 102 patients were included. VO was defined as a VFV above the 75 percentile. Thirteen (12.7%) patients developed AL, four (15.4%) of whom were in the VO group (p = 0.900). At least one postoperative complication developed in 38 (37.3%) patients, with no significant difference between the VO and non-VO patients after univariable analysis (42.3% vs. 35.4%, p = 0.702) or multivariable adjustment (OR 1.01, 95% CI 0.38-2.65, p = 0.984). VO was significantly associated with an increased incidence of conversion to open surgery (OR 4.30, 95% CI 1.29-14.86, p = 0.018). There was a significant difference in the number of harvested lymph nodes between the two groups (mean 23.5 vs. 29.1, p = 0.045). CONCLUSIONS: In this study on patients undergoing laparoscopic rectal resection, VO was not associated with development of AL or other complications. However, we found that visceral obesity was associated with an increased risk of conversion to open surgery.

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery.

BACKGROUND: In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis. METHODS: Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control. RESULTS: In total, 1179 patients who underwent major emergency abdominal surgery during 2010-2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11-2.16, P = 0.009). CONCLUSION: In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

Surgical management of acute cholecystitis in a nationwide Danish cohort.

PURPOSE: In the Danish national guidelines from 2006 on the treatment of acute cholecystitis, early laparoscopic operation within 5 days after the debut of symptoms was recommended. The aim of this study was to analyze the outcome in patients with acute cholecystitis subjected to cholecystectomy in Denmark in the five-year period hereafter. METHODS: All patients undergoing cholecystectomy in the period 2006-2010 were registered in the Danish Cholecystectomy Database, from which outcome data were collected. The effect of potential risk factors such as age, gender, BMI, American Society of Anesthesiologists (ASA) score, previous pancreatitis, previous abdominal surgery, year of operation, surgical approach, and surgeon experience was analyzed. RESULTS: Of 33,853 patients registered with a cholecystectomy, 4667 (14%) were operated for acute cholecystitis. In 95% of the patients, laparoscopic cholecystectomy was intended and in 5% primary open access was chosen. The frequency of conversion from laparoscopic to open surgery was 18%. High age and ASA score, operation in the early years of the period, and open or converted procedure all increased the risk of hospital stay to > 3 days or readmission. High age and ASA score, converted or open operation, and previous pancreatitis increased the risk of additional procedures. Postoperative mortality was 1.2%, and significant risk factors for postoperative death were age, low BMI, high ASA score, early year of operation, and open procedures. CONCLUSIONS: Acute cholecystectomy was safely managed laparoscopically in most patients after the introduction of national guidelines, with an increasing rate of laparoscopically completed procedures during the study period.

Enhanced recovery after abdominal wall reconstruction reduces length of postoperative stay: An observational cohort study.

BACKGROUND: Enhanced recovery after surgery has been shown to lead to improved postoperative outcomes after several surgical procedures. However, only a few studies have examined the application of enhanced recovery after surgery after abdominal wall reconstruction. The aim of the current observational cohort study was to evaluate the outcomes of enhanced recovery after surgery after abdominal wall reconstruction in a large cohort. METHOD: This was a retrospective cohort study comparing patients undergoing abdominal wall reconstruction in a standard care pathway (control group) with patients undergoing abdominal wall reconstruction in an enhanced recovery after surgery pathway. Registered outcomes included 30-day postoperative complications, length of stay, and readmission rate. RESULTS: A total of 190 patients undergoing abdominal wall reconstruction for large incisional hernias were included in the study, of which 96 were treated according to standard protocol, and 94 underwent enhanced recovery after surgery pathway. Length of stay was significantly reduced after the introduction of enhanced recovery after surgery (median 4, interquartile range 3-6 days vs. control 5, 4-7 days, P < .001). There was no difference between the cohorts in the incidence of postoperative complications requiring operative intervention (enhanced recovery after surgery 10.6% vs control 10.4%, P = 1.0) or the rate of readmissions (enhanced recovery after surgery 16.0% vs control 12.5%, P = .635). CONCLUSION: Enhanced recovery after surgery is feasible after abdominal wall reconstruction, leading to reduced length of stay without increasing the rate of complications or readmissions. Enhanced recovery should be implemented as standard in centers performing abdominal wall reconstruction.

Nationwide cross-sectional study of Danish surgeons' professional use of social media.

INTRODUCTION: The extent of professional social media (SM) engagement by Danish surgeons remains unknown. It may be important for Danish surgeons to engage in SM, not only to establish and maintain an international network, but also to stay up to date on new developments in the international surgical community. The aim of the present study was to describe Danish surgeons' professional engagement in SM. METHODS: This was a descriptive cross-sectional study surveying all registered Danish surgeons who were members of the Danish Medical Association by May 2017. An online questionnaire was sent to all identified surgeons twice eight days apart. The questionnaire contained questions about the use of SM for professional purposes. RESULTS: The total response rate was 40.8%. After exclusion of non-active surgeons, a total of 261 respondents were included in the study. Of these, 81 (30.0%) reported to be engaged in SM professionally. Surgeons actively using SM professionally were younger (mean age 53.8 versus 57.6 years, p = 0.018) and had more often been scientifically active within the past year (64.1% versus 48.6%, p = 0.032) compared with surgeons who were not using SM professionally. Of those who were not engaged in SM professionally, 33 (18.3%) replied that they would consider using SM for professional purposes if they received help in doing this. CONCLUSIONS: One third of surgeons in Denmark seem to be actively engaged in SM for professional purposes. The findings of the present study suggest that a potential for further SM involvement exists. FUNDING: none. TRIAL REGISTRATION: none.

Oncological outcome following laparoscopic versus open surgery for cancer in the transverse colon: a nationwide cohort study.

BACKGROUND: The literature on transverse colonic cancer resection is sparse. The optimal surgical approach for this disease is thus unknown. This study aimed to examine laparoscopic versus open surgery for transverse colonic cancer. METHODS: This study was a nationwide, retrospective cohort study of all patients registered with a transverse colonic cancer in Denmark between 2010 and 2013. Data were obtained from the Danish Colorectal Cancer Group, the Danish Pathology Registry, Danish National Patient Registry, and patients' records. Main outcome measures were surgical resection plane, lymph node yield, and long-term cancer recurrence and survival. RESULTS: In total, 357 patients were included. Non-mesocolic resection was more frequent with laparoscopic compared with open resection (adjusted odds ratio 2.44, 95% CI 1.29-4.60, P = 0.006). Median number of harvested lymph nodes was higher after open compared with laparoscopic resection (22 versus 19, P = 0.03). Non-mesocolic resection (adjusted hazard ratio 2.45, 95% CI 1.25-4.79, P = 0.01) and increasing tumor stage (P < 0.001) were factors associated with recurrence. Cancer recurrence was significantly associated with an increased risk of mortality (adjusted hazard ratio 4.32, 95% CI 2.75-6.79, P < 0.001). Overall mortality was, however, not associated with the surgical approach or surgical plane. CONCLUSIONS: Although associated with a lower rate of mesocolic resection plane and fewer lymph nodes harvested, laparoscopic surgery for transverse colonic cancers led to similar long-term results compared with open resection.