Impact of COVID-19 on clinical outcomes of robotic inguinal hernia repair.

PURPOSE: To investigate the impact of the COVID-19 pandemic on the clinical impact of the clinical outcomes of robotic inguinal hernia repair. METHODS: Patients who underwent RIHR 2 years before and after March 10, 2020, were included in this retrospective study and assigned accordingly to the pre- or post-COVID group. Pre-, intra-, and postoperative variables including patients' demographics, hernia characteristics, complications, and hernia recurrence rates were compared between groups. RESULTS: 183 (94.5% male) and 141 (96.4% male) patients were assigned to the pre- and post-COVID groups, respectively. Patient demographics and medical comorbidities did not differ between groups. Operative time was approximately 40 min longer in the post-COVID group (p < 0.001) with higher rates of bilateral IHR (pre-COVID: 30.1% vs. post-COVID: 46.4%, p = 0.003). Mesh material differed between groups with predominance of polyester mesh in the pre-COVID group vs. polypropylene in the post-COVID one. Median hospital length of stay (LOS) was 0 days in both groups, and same-day discharge rates were 93.4% pre-pandemic and 92.8% post-pandemic (p = 0.09). There were no pulmonary complications recorded in either group or no cases of COVID-19 detected within two weeks postoperatively in the post-COVID group. Seromas were more frequent in the post-COVID group (pre-COVID: 2 vs. post-COVID: 8, p = 0.018) and no hernia recurrences were recorded. CONCLUSION: This is the first study to describe the impact of COVID-19 on RIHR. Clinical outcomes and hernia-specific complications were not impacted by the COVID-19 pandemic.

A comparison of outcomes between class-II and class-III obese patients undergoing robotic ventral hernia repair: a multicenter study.

BACKGROUND: Morbid obesity has been considered a contraindication to ventral hernia repair (VHR) in the past. However, the relationship between a greater body mass index (BMI) and adverse outcomes has yet to be established in the minimally invasive sphere, particularly with robotics, which may offer an effective surgical option in these high-risk patients. We sought to investigate this relationship by comparing the outcomes of class-II (BMI: 35-39.9 kg/m2) and class-III (BMI: ≥ 40 kg/m2) obese patients after robotic VHR (RVHR). METHODS: Data were analyzed from two centers and six surgeons who performed RVHR between 2013 and 2020. Patients with a BMI > 35 kg/m2 were included in the study. A 1:1 propensity score match (PSM) analysis was conducted to obtain balanced groups and univariate analyses were conducted to compare the two groups across preoperative, intraoperative, and post-operative timeframes. Postoperative complications and morbidity were reported according to the Clavien-Dindo Classification and comprehensive complication index (CCI®) systems. RESULTS: From an initial cohort of 815 patients, 228 patients with a mean BMI of 39.7 kg/m2 were included in the study. PSM analysis stratified these into 69 patients for each of the class-II and class-III groups. When comparing matched groups, there were no differences in any of the variables across all timeframes, except for a higher rate of Polytetrafluoroethylene (PTFE)-based mesh use in the class-III group (39.1% vs 17.4%, p = 0.008). The estimated recurrence-free time was 76.4 months (95% CI = 72.5-80.4) for the class-II group and 80.4 months (95% CI = 78-82.8) for the class-III group. CONCLUSION: This multicenter study showed no difference in outcomes after RVHR between matched class-II and class-III obese patients.

Comparison of perioperative outcomes between non-obese and obese patients undergoing robotic inguinal hernia repair: a propensity score matching analysis.

PURPOSE: Despite the limited research in support of robotic inguinal hernia repair (RIHR), it is an increasingly adopted technique in surgical practice. While a major risk factor for the development of ventral hernias and subsequent complications, obesity in RIHR has not been investigated. The aim of this study was to compare the outcomes of RIHR between obese and non-obese patients. METHODS: Prospectively collected data surrounding RIHRs performed at a single center between 2013 and 2020 were retrospectively reviewed. Patients were divided into non-obese (< 30 kg/m2) and obese (≥ 30 kg/m2) groups, and preoperative, intraoperative, and postoperative variables were compared in unmatched and matched groups, derived using a 1:2 propensity score match (PSM). RESULTS: From a total of 547 patients, 414 were non-obese and 133 were obese. A PSM analysis, accounting for confounding preoperative variables and risk factors, stratified these into 262 patients for the non-obese group and 131 patients for the obese group. Although the obese group's operative times were longer on average (57 min vs. 51 min; p = 0.007), this difference did not persist after matching. The only significant difference in operative variables was a higher rate of cord lipomas in the obese group. Postoperative variables, including wound complications, readmissions, and recurrence, were similar across unmatched and matched groups. CONCLUSION: In the first study to investigate the influence of obesity in RIHR, no differences in outcomes were found between obese and non-obese patients. This procedure can be safely performed in obese individuals, however, more studies comparing body mass index (BMI) classes are needed to establish whether a prohibitive BMI threshold exists for RIHR.

Lateral approach totally extraperitoneal (TEP) robotic retromuscular ventral hernia repair.

BACKGROUND: The enhanced (or extended) view total extraperitoneal (TEP) access that was initially described for laparoscopic inguinal hernia repair has been applied to first laparoscopic and now robotic retromuscular ventral hernia repair (RRVHR). However, a 'dynamic' port setup that is based on the area of interest is preferred by most surgeons. In this study, we present our center's early operative outcomes after utilizing a lateral approach TEP-access RRVHR with and without transversus abdominis release (TAR). METHOD: An evaluation of a prospectively maintained database of hernia patients was conducted identifying patients who underwent a lateral approach TEP-access RRVHR between February 2013 and April 2019. The lateral approach TEP-access RRVHR was described. Patient demographics, intraoperative and postoperative variables were reviewed. Preoperative and postoperative results were presented according to recommended classification systems by European Hernia Society. RESULTS: Fifty-two patients who underwent a lateral approach TEP-access RRVHR were included in this study. A lateral dock setup was utilized for all patient who had a midline defect, as well as a lateral defect. The mean console time was 121.6 min., skin-to-skin time was 138.5 min. There was no intraoperative complication or conversion. The mean hospital length of stay was 0.71 day. During the mean 6.5 months follow-up period, no hernia recurrence arose. CONCLUSION: The lateral approach TEP-access RRVHR with and without TAR is a reproducible technique. Feasibility of this approach needs to be demonstrated by other surgeons familiar with retromuscular hernia repair in addition to long-term follow up.

Propensity score matching analysis of short-term outcomes in robotic ventral hernia repair for patients with a body mass index above and below 35 kg/m2.

OBJECTIVE: The purpose of this study was to compare perioperative complications after robotic ventral hernia repair between patients with non-obese, class-I obesity with those with class-II or class-III obesity. BACKGROUND: Obesity is a growing epidemic and is considered as an independent risk factor for a multitude of perioperative complications. Laparoscopic ventral hernia repair has been shown as a safe and feasible approach in population with elevated body mass index (BMI). This study compared overall perioperative complications and surgical site events (SSEs) after robotic ventral hernia repair (RVHR) between patients with a BMI 35 kg/m2 or more and patients with a BMI lower than 35 kg/m2. METHODS: A retrospective cohort analysis was conducted with one-to-one propensity score matching (PSM) method to obtain balanced groups evaluating patients who underwent RVHR between February 2012 and June 2019 in a single institution. Preoperative, intraoperative, and postoperative variables were reviewed. Postoperative complications and morbidity were assessed using the Clavien-Dindo classification and comprehensive complication index (CCI®) score system. SSEs were compared. RESULTS: Our unmatched sample included 526 patients with an average BMI of 31.2 kg/m2. Of these, 29.8% (n = 160) patients were in high-BMI group (range 35-59.2). After PSM, 142 patients were assigned to each group. Both groups experienced similar complication rates during 90 days. Clavien-Dindo grades, CCI® scores, and SSEs did not differ between the two groups. CONCLUSION: RVHR in class-II and class-III obese patients is safe, feasible, and effective. In addition to this, it has comparable short-term outcomes with those non-obese and class-I obese patients.

Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis.

PURPOSE: rTAPP-VHR is a novel technique which may be added to a surgeon's armamentarium. We aim to evaluate the robotic transabdominal preperitoneal ventral hernia repair (rTAPP-VHR) learning curve based on operative times while accounting for peritoneal flap integrity. METHODS: We performed a retrospective analysis of a database collected over a 7-year period. Patients with primary ventral hernias were included and a cumulative sum analysis(CUSUM) was used to create learning curves for three subsets of operative times. A risk-adjusted CUSUM (RA-CUSUM) accounted for repair quality based on peritoneal flap completeness. The flap was considered as incomplete when peritoneal gaps were unable to be closed. RESULTS: 105 patients undergoing rTAPP-VHR were included. Learning curves were created for skin-to-skin, console, and off-console times. Patients were divided into three phases. In terms of skin-to-skin times, both phase 2&3 had a mean 11 min shorter than that of phase 1 (p = 0.0498, p = 0.0245, respectively), with a steady decrease after forty-six cases. An incomplete peritoneal flap was noted in 25/36 patients in phase 1, as compared to 5/24 and 5/45 patients in phase 2&3, respectively. When risk-adjusted for peritoneal flap completeness, gradually decreasing skin-to-skin times were observed after sixty-one cases. In terms of off-console times, the mean across three phases was 14 min, with marked improvement after forty-three cases. CONCLUSIONS: Forty-six cases were needed to achieve steadily decreasing operative times. We can assume that ensuring good-quality repairs, through maintenance of peritoneal flap integrity, was gradually improved after sixty-one cases. Moreover, familiarization with port placements and robotic docking was accomplished after forty-three cases.

A comparison of robotic mesh repair techniques for primary uncomplicated midline ventral hernias and analysis of risk factors associated with postoperative complications.

PURPOSE: We aim to compare short-term outcomes of robotic intraperitoneal onlay (rIPOM), transabdominal preperitoneal (rTAPP) and retromuscular (rRM) repair for uncomplicated midline primary ventral hernias (PVH) and determine risk factors associated with postoperative complications. METHODS: The three groups were compared in terms of pre-, intra-, and post-operative variables. Postoperative complications were assessed using previously validated classifications. Univariate analyses were conducted to determine which variables influence postoperative complications (up to 90 days), followed by a multivariate regression analysis revealing statistically important risk factors. RESULTS: A total of 269 patients who underwent robotic PVH repair patients were grouped as rIPOM (n = 90), rTAPP (n = 108), and rRM (n = 71). rRM repair allowed for the use of larger-sized meshes for larger defects; however, it was associated with higher-grade complications. rTAPP repair resulted in the lowest morbidity and offered the highest mesh-to-defect ratio for smaller-sized hernias. Operative time for the rRM group was longer. The rIPOM group had a higher morbidity, likely due to higher frequency of minor complications, as compared to rTAPP and rRM groups. Multivariate regression analysis revealed that coronary artery disease, absence of defect closure, intraperitoneally placed mesh, and skin-to-skin time (minutes) were significantly associated with postoperative complications. CONCLUSION: Robotic PVHR contributes multiple techniques to a surgeon's armamentarium, such as IPOM, TAPP, and RM mesh placements. Patient characteristics as well as the potential consequences of each technique need to be taken into consideration when deciding the appropriate approach for the repair of primary uncomplicated midline ventral hernias.

Short-term comparison between preperitoneal and intraperitoneal onlay mesh placement in robotic ventral hernia repair.

PURPOSE: The aim of this study was to compare perioperative results of robotic IPOM (r-IPOM) and robotic TAPP (r-TAPP) in ventral hernia repair, and to identify risk factors associated with postoperative complications. METHODS: After obtaining balanced groups with propensity score matching, the comparative analysis was performed in terms of perioperative and early outcomes. All variables were also examined in a subset analysis in patients with and without complications. Multivariable regression analysis was used to identify independent risk factors associated with the development of complications. RESULTS: Of 305 r-IPOM and r-TAPP procedures, 104 patients were assigned to each group after propensity score matching. There was no difference in operative times between two groups. Although postoperative complications were largely minor (Clavien-Dindo grade-I and II), the rate of complications was higher in the r-IPOM group within the first 3-weeks (33.3% in r-IPOM vs. 20% in r-TAPP, p = 0.039). At the 3-month visit, outcomes between groups were not different (p = 0.413). Emergency department re-visits within 30-days and surgical site events were also higher in the IPOM group (p = 0.028, p = 0.042, respectively). In regression analysis, the development of complications was associated with incisional hernias (p = 0.040), intraperitoneal mesh position (p = 0.046) and longer procedure duration (p = 0.049). CONCLUSION: Our data suggest r-IPOM may be associated with increased complication rates in the immediate postoperative period when compared to r-TAPP. However, at 3 months, outcomes are comparable. More investigation is needed in this area, specifically with regards to long-term follow-up and multicenter data, to determine the true value of extra-peritoneal mesh placement.

Robotic retromuscular ventral hernia repair and transversus abdominis release: short-term outcomes and risk factors associated with perioperative complications.

BACKGROUND: Retromuscular ventral hernia repairs have become increasingly popular, both with and without transversus abdominis release. We aim to describe our 90-day outcomes in patients who underwent robotic retromuscular ventral hernia repair (RRVHR). METHODS: All patients were subcategorized into those who underwent a TAR (TAR+) as part of their repair, and those who did not (TAR-). Patient demographics, comorbidities, hernia characteristics, and LOS were studied. Perioperative complications were reviewed in four different time frames up to 90 days. All hernias and complications were classified using the recommended classification systems. Appropriate univariate analyses and multivariate regression analyses were performed to determine the hernia characteristics which required a TAR technique, and risk factors which associated with the development of complications. RESULTS: Of 454 robotic ventral hernia repairs, 101 patients who underwent RRVHR were included into the study. Of these, 54 patients underwent RRVHR with TAR while the remaining 47 patients underwent repair without TAR. Incisional hernias, off-midline locations, and larger size defects were factors that required the addition of a TAR. In 9.9% patients, an unplanned TAR was performed. Postoperative pain assessment was similar in both groups. LOS was significantly longer for TAR + group (p < 0.001). The median Comprehension Complication Index® score was 8.7 (range: 0-42.4) for all patients and was significantly higher for TAR+ group (p = 0.014). Complications were higher in the TAR+ group as compared to the TAR- group (p = 0.028), though this difference did not persist in follow-up. Most complications were minor (Clavien-Dindo grade-I and -II). The development of complications was only associated with the presence of an incarcerated hernia at repair. CONCLUSION: RRVHR is safe and feasible. 9.9% of our cohort required a TAR that was unplanned, particularly incisional hernias. TAR patients may be more prone to complications in the immediate post-operative period, however, the difference between patients with and without TAR adjuncts resolved at 90 days.