A comparison of clinical outcomes and costs between robotic and open ventral hernia repair.

BACKGROUND: As robotic ventral hernia repair(VHR) adoption increases, real-world evidence is needed to ensure appropriate utilization. METHODS: Data for open and robotic VHR(OVHR, RVHR) was retrospectively analyzed. Outcomes and costs were compared via inverse probability treatment weighting using propensity scores to estimate the average treatment effect on the treated for RVHR. RESULTS: 675 open and 609 robotic ventral hernia repairs were included. Demographics and hernia characteristics were comparable. Complications rates were lower in RVHR(p < 0.001). Clavien-Dindo grade-III complications were lower in RVHR(13.2% vs. 4.9%, p < 0.001). RVHR resulted in fewer surgical site events(21.5% vs. 12.2%, p < 0.001). Recurrence rates were greater in OVHR(8.9% vs. 2.8%, p < 0.001). The higher RVHR hospital costs (Δ = $2456, p = 0.005) were balanced by the lower post-discharge costs, compared to OVHR(Δ = $799, p = 0.023). Total costs did not differ(Δ = $1656 p = 0.081). CONCLUSION: Although hospital costs were higher, post-discharge expenses favored RVHR due to the lower postoperative complications, which lead to comparable total costs to OVHR.

Analysis of Factors Associated with Same-Day Discharge After Robotic Transversus Abdominis Release for Incisional Hernia Repairs.

Background: Advancement in surgery has shifted numerous procedures to a same-day discharge (SDD) setting. In this study, we evaluated factors related to SDD after robotic transversus abdominis release (rTAR). Materials and Methods: A retrospective analysis of a prospectively maintained hernia databank was performed. Patients who underwent rTAR for incisional hernias were assigned to either the SDD group (length of stay [LOS] <1) or the inpatient group (LOS ≥1 day). Pre-, intra-, and postoperative variables were compared. Predictors of SDD were explored through a logistic regression, and a mediation analysis was performed to assess their effect on the LOS. Results: Out of the 167 patients included, 53 patients were discharged the same day. Age, American Society of Anesthesiologists score, history of coronary artery disease, and wound infection were significantly higher in the inpatient group. Overall, median LOS was 1 (0-2). Postoperative complications did not differ between SDD and inpatient groups except for Clavien-Dindo Grade-II (1 versus 14, respectively; P = .039). Thirty-day readmission rates were comparable (P = .229). A binary logistic regression to predict factors associated with SDD rTAR showed statistical significance in age, operative time, mesh area, and history of wound infection. Mediation analysis showed that mesh size indirectly affected the LOS through the operative time (a = 0.54; b = 0.46; P < .001). An age >46-year-old, an operative time beyond 217 minutes, and a mesh size >475 cm2 increased the probability of an inpatient stay (area-under-the-receiver operating characteristic curves: 0.69, 0.81, and 0.82, respectively). Conclusion: The pre- and intraoperative factors associated with SDD rTAR were age, history of wound infection, operative time, and mesh area. Further studies are needed to investigate the appropriateness of discharge decisions while balancing patients' benefits, resource utilization, and costs.

Quality of life and surgical outcomes of robotic retromuscular ventral hernia repair using a new hybrid mesh reinforcement.

PURPOSE: The purpose of this study is to prospectively evaluate surgical and quality of life (QoL) outcomes of robotic retromuscular ventral hernia repair (rRMVHR) using a new hybrid mesh in high-risk patients. METHODS: Data was prospectively collected for patients classified as high-risk based on the modified ventral hernia working group (VHWG) grading system, who underwent rRMVHR using Synecor™ Pre hybrid mesh in a single center, between 2019 and 2020. Pre-, intra- and postoperative variables including hernia recurrence, surgical site events (SSE), hernia-specific quality of life (QoL), and financial costs were analyzed. QoL assessments were obtained from preoperative and postoperative patient visits. Kaplan-Meier survival analysis was performed to analyze the estimated recurrence-free time. RESULTS: Fifty-two high-risk patients, with a mean (±SD) age of 58.6 ± 13.7 years and BMI of 36.9 ± 6.6 kg/m2, were followed for a mean (±SD) period of 22.4 ± 7.1 months. A total of 11 (21.2%) patients experienced postoperative complications, out of which eight were SSEs, including 7 (13.5%) seromas, 1 (1.9%) hematoma, and no infections. Procedural interventions were required for 2 (3.8%) surgical site occurrences. Recurrence was seen in 1 (1.9%) patient. The estimated mean (95% confidence interval) recurrence-free time was 33 (32.3-34.5) months. Postoperative QoL assessments demonstrated significant improvements in comparison to preoperative QoL, with a minimum ∆mean (±SD) of -15.5 ± 2.2 at one month (p < 0.001). The mean (±SD) procedure cost was $13,924.18 ± 7856.95 which includes the average mesh cost ($5390.12 ± 3817.03). CONCLUSION: Our study showed favorable early and mid-term outcomes, in addition to significant improvements in QoL, after rRMVHR using Synecor™ hybrid mesh in high-risk patients.

SAVE 2.0: Identifying and strengthening resident leadership skills through simulation based team training.

BACKGROUND: The "Surgery for Abdomino-thoracic ViolencE (SAVE)" animate lab engages surgical residents in the management of penetrating injuries in a team setting. Senior residents, representing postgraduate year (PGY) 3-5, assume the role of team leader and facilitate the junior residents, PGY1-2, in operative management of simulated penetrating wounds. Residents completed five scenarios with increasing level of difficulty within set time limits. Senior residents were evaluated on their team's ability to "SAVE" their patient within the time allotted, as well as their communication and leadership skills. METHODS: General, vascular, urology, and plastic surgery residents (n = 79) were divided into 25 teams of three to four residents by "resident scores" (R scores, the sum of the team members' PGY) to create balanced teams with comparable years of clinical experience. Residents completed assessments of their senior resident's leadership ability and style. RESULTS: Evaluation of a resident's desired learning style changed across PGY with junior residents preferring more hands-on guidance compared with senior residents preferring only verbal correction. Resident leadership evaluations demonstrated that team leaders of varied resident years achieved the highest scores. Greater differences in the mismatch between autonomy provided to and desired by junior residents correlated to greater junior resident discomfort in expressing their opinion, confidence, and leadership ratings of senior residents. However, greater autonomy mismatch also correlated to more rapid time to task completion. CONCLUSION: Different from our expectations, clinical experience alone did not define team leader success. Leadership is a powerful influence on the outcome of team performance and may be a skill, which can transcend overall clinical experience. A match between desired and provided resident autonomy and team cohesion may demonstrate a stronger effect on team success in stressful operative situations, such as trauma resuscitation. Enhancement of leadership skills early in residency training may represent an important focus for trauma surgery education.

Anatomy of Gun Violence: Contextualized Curriculum to Train Surgical Residents in Both Technical and Non-Technical Skills in the Management of Gun Violence.

BACKGROUND: Gun violence (GV) is a complex public health issue, and the management of GV as a disease engages the surgeon in technical and nontechnical skills. The Anatomy of Gun Violence (AGV) curriculum was developed to teach surgical trainees these seemingly disparate skills, training residents to manage the multiple aspects of firearm injury. STUDY DESIGN: The AGV curriculum was delivered over 6 weeks in the 2017-2018 and 2018-2019 academic years (AY), and used multiple educational methods including didactic lectures, mock oral examinations, a Bleeding Control training session, a GV survivor's personal story, a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) training session, and the Surgery for Abdominal-thoracic ViolencE (SAVE) simulation lab. As surgical residents were involved over both AYs, components of the curriculum were available every other year to provide variety. As proof of concept, this novel curriculum was objectively evaluated by residents' improvement in knowledge and overall experience using pre- and post-surveys. RESULTS: Sixty surgical residents participated in the AGV curriculum in both AYs, with 41 and 36 residents completing the survey regarding their experiences with the curriculum. The curriculum was well received by residents overall in both AYs (median ± IQR 5 ± 0 and 5 ± 0.1, respectively), with the SAVE simulation lab being the most highly favored portion. Additionally, residents had an average 7.5% improvement in knowledge attributed to the curriculum, with a larger effect seen in the junior residents. CONCLUSIONS: This novel AGV curriculum created a well-received learning experience involving the technical and nontechnical skills necessary to care for GV victims. This comprehensive approach to GV may represent a unique opportunity to engage surgical trainees in both the treatment and prevention of firearm injury.