Intraoperative complications of robotic-assisted extended totally extraperitoneal (eTEP) ventral hernia retromuscular repairs with mesh: a systematic literature review and narrative synthesis.

Minimally invasive extended totally extraperitoneal (eTEP) technique is revolutionising ventral hernia repairs. Robotic-assisted eTEP has been gaining popularity due to better visual clarity and greater dexterity provided by the robotic systems, compared to laparoscopy. Despite growing number of papers being published each year, so far, no study has explored intraoperative complications in robotic-assisted eTEP. The aim was to perform a systematic literature review on the incidence of intraoperative complications in robotic-assisted eTEP ventral hernia repairs. The study protocol was preregistered with PROSPERO, registration number CRD42023450072. Twelve categories of intraoperative complications were defined by the authors. A search of PubMed and Embase was conducted on 16/08/2023, for articles pertaining to robotic-assisted eTEP operations in ventral hernias in adults. Articles were critically appraised and data were extracted using predefined extraction templates. No data were suitable for statistical analysis and a narrative synthesis was performed instead. Ten studies fulfilled the inclusion criteria, of which four studies reported intraoperative complications. Of the 12 categories of intraoperative complications, only 5 were reported. Three studies encountered adherent bowel inside the hernia sac. One reported linea alba injury with subsequent anterior layer dehiscence. There was one case of unrecognised intraoperative retromuscular bleeding and one case of insufflation injury with subcutaneous emphysema. There is a paucity of literature on the incidence of intraoperative complications in robotic-assisted eTEP ventral hernia repairs. Available studies suggest complication rates are low. More robust studies using prospective data from hernia registries are required before further conclusions can be drawn.

The use of a porcine model to teach advanced abdominal wall dissection techniques.

BACKGROUND: In the era of minimally invasive surgery, it is clear that a robust simulation model is required for the training of surgeons in advanced abdominal wall reconstruction. The purpose of this experimentation was to evaluate whether a porcine model could be used to teach advanced minimally invasive abdominal wall dissection techniques to novice surgeons. Secondary objectives included: time to completion, identification of various anatomical landmarks, to note the difference in porcine and human models and finally, the ability to dock a Da Vinci Xi robotic platform on the porcine model. METHODOLOGY: Two post-fellowship surgeons were given the task of performing an extended total extraperitoneal dissection (ETEP) on one female Landrace pig under the supervision of a surgeon experienced in robotic-assisted ventral hernia repair. This included insertion of ports, developing a retro-rectus plane, crossover from left to right rectus, bilateral transverse abdominus release, and sub-diaphragmatic dissection. A 5-mm vessel sealer was used to facilitate the dissection. The steps of the surgery were given to the trainees, and an experienced hernia surgeon guided the steps of dissection. The emphasis of the tasks was to develop the planes of extraperitoneal dissection to demonstrate that the porcine model could be considered for a viable and realistic model for training. RESULTS: The candidates were able to successfully complete the task and dock a Da Vinci Xi with the porcine model providing a realistic platform for training. CONCLUSION: The porcine model can be a considerable tool in the education of surgeons embarking on learning the art of minimally invasive abdominal wall reconstruction techniques. The advantage of live tissue dissection, similarity in anatomy and the relatively inexpensive availability of porcine models, makes it an unparalleled form of simulation-based training. We believe that this will have transitional capabilities to robotic ETEP education for complex hernia repair.

Robot-assisted general surgery is safe during the learning curve: a 5-year Australian experience.

Robot-assisted general surgery has become increasingly common in the Australian public sector since 2003. It provides significant technical advantages compared to laparoscopic surgery. Currently, it is estimated that the learning curve for surgeons starting off with robotic surgery is complete after 15 cases. This is a retrospective case series, following the progress of four surgeons with minimal robotic experience over 5 years. Patients undergoing colorectal procedures and hernia repairs were included. 303 robotic cases were included in this study, 193 colorectal surgeries and 110 hernia repairs. 20.2% of colorectal patients experienced an adverse event and 10.0% of hernia patients had a complication. The learning curve was correlated to the average docking time, and it was found that this was complete after 2 years, or after a minimum of 12 to 15 cases. Patient length of stay decreases as surgeon experience increases. Robotic surgery is a safe approach to colorectal surgery and hernia repairs with some potential benefits in terms of patient outcomes as surgeon experience increases.

Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair.

INTRODUCTION: The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes. METHODS: A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre-optimization pathways were then compared with a recent Delphi consensus statement. RESULTS: Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre-optimization and plan the definitive repair. These pre-optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well-defined referral criteria, perioperative high-risk management with pre-optimization, surgical planning, postoperative care and follow-up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness. CONCLUSIONS: CAWH MDT can provide comprehensive, patient-centred care with improved postoperative outcomes. CQR are important to better evaluate long-term outcomes and ensure rigorous quality control.

Mesh versus non-mesh repair of groin hernias: a rapid review.

BACKGROUND: Mesh is frequently utilized intraoperatively for the repair of groin hernias. However, patients may request non-mesh hernia repairs owing to adverse events reported in other mesh procedures. To inform surgical safety, this study aimed to compare postoperative complications between mesh and non-mesh groin hernia repairs and identify other operative and patient-related risk factors associated with poor postoperative outcomes. METHODS: Ovid MEDLINE and grey literature were searched to 9 June 2021 for studies comparing mesh to non-mesh techniques for primary groin hernia repair. Outcomes of interest were postoperative complications, recurrence of hernia, pain and risk factors associated with poorer surgical outcomes. Methodological quality was appraised using the AMSTAR 2 tool. RESULTS: The systematic search returned 4268 results, which included seven systematic reviews and five registry analyses. Mesh repair techniques resulted in lower hernia recurrence rates, with no difference in chronic pain, seroma, haematoma or wound infection, compared to non-mesh techniques. Risk factors associated with increased risk of hernia recurrence were increased body mass index (BMI), positive smoking status and direct hernia. These were independent of surgical technique. Patients under 40 years of age were at increased risk of postoperative pain. CONCLUSIONS: Surgical repair of primary groin hernias using mesh achieves lower recurrence rates, with no difference in safety outcomes, compared with non-mesh repairs. Additional risk factors associated with increased recurrence include increased BMI, history of smoking and hernia subtype.

Elective abdominal wall hernia repair surgical mortality-A systematic review of the literature and peer review of mortality in Australia.

BACKGROUND: This study systematically reviewed the literature regarding perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair, including an audit of the Royal Australasian College of Surgeons (RACS) Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. METHODS: A systematic review was conducted in accordance with PRISMA guidelines for the reporting of systematic reviews and meta-analysis of observational studies. Cochrane Library, PubMed, MEDLINE and Embase database searches and data extraction were conducted from June 1979 to October 2019. Statistical analysis was undertaken utilising denominator values for elective hernia procedures derived from the Australian Institute of Health and Welfare (AIHW) data. Risk-adjusted perioperative mortality rates for the relevant procedures were also produced, using a binary logistic regression for the risk adjustment. RESULTS: Through systematic review of the literature, it was established that the overall reported perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair was low (0.1%-0.5%). Using ANZASM and AIHW data, the calculated risk-adjusted mortality rate for Australian patients was found to be significantly lower (0.04%-0.06%, p < 0.001). CONCLUSION: The risk-adjusted mortality rate for elective abdominal wall hernia surgery in Australia is very low and compares favourably to international cohorts. Despite low absolute numbers, the factors which were most significantly associated with increased perioperative mortality in patients undergoing elective surgical abdominal wall hernia repair were increased age, cardiorespiratory co-morbidity and incisional hernia repair.

Developing a Hernia Mesh Tissue Integration Index Using a Porcine Model-A Pilot Study.

Introduction: With so many prosthetics available, it can be difficult for surgeons to choose the most appropriate hernia mesh. Successful hernia repair mandates an understanding of how the patient's inflammatory response influences surgical outcomes. Failure to appreciate the importance of the biological aspect of hernia repair can be very costly as emerging evidence supports that biofilm formation and reduction in effective mesh porosity gives rise to long-term mesh complications including fibrosis, chronic mesh infection, and pain. In this pilot study, we utilized a large animal (porcine) model to develop a numerical Mesh Tissue Integration (MTI) Index focused on visible tissue ingrowth, fibrosis, adhesion formation and resorption of mesh. The aim is to help surgeons adopt an evidence-based approach in selecting the most appropriate mesh according to its tissue ingrowth characteristics, matched to the patient to achieve improved surgical outcomes and optimal patient-centered care. Methods: Two forty kg female Landrace pigs were recruited for this pilot study. A total of eight commonly used hernia mesh products and two controls measuring 5 × 5cm were surgically implanted in subrectus and intraperitoneal planes. The pigs were euthanised at 2 and 4 weeks, respectively. The abdominal wall was explanted, and the mesh specimens underwent macroscopic, histologic and biomechanical analysis, with engineering and pathology teams blinded to the mesh. Results: Significant differences between the degrees of MTI were observed at 2 weeks and the distinctions were even more apparent at 4 weeks. One of the interesting incidental findings we observed is that mesh products placed in the subrectus plane displayed greater degrees of adhesion strength and integration than those placed intraperitoneally. Conclusion: This pilot study is one of the first to propose a functional, biological standardized model for comparing hernia mesh products. The results are encouraging and demonstrate that this is a robust and transferrable model for assessing MTI in hernia mesh. The intention for this model is that it will be utilized synergistically with long term mesh/patient outcome registries and databases to inform improved matching of mesh to patient, particularly in the setting of the complex hernia repair and abdominal wall reconstruction.

Robotic-assisted ventral hernia repair with surgical mesh: how I do it and case series of early experience.

BACKGROUND: Laparoscopic ventral hernia repair provides several benefits over the open approach. Intraperitoneal surgical mesh placement without fascial defect closure is associated with increased seroma formation and other adverse hernia-site outcomes. Transfascial sutures and tacs for fascial closure and surgical mesh fixation are associated with greater post-operative pain. Robotic-assisted ventral hernia repair (rVHR) may afford benefits of the laparoscopic approach while facilitating a more robust and less painful repair. METHODS: Consecutive patients managed by rVHR from May 2015 to August 2018 were identified from a prospectively maintained robotic database. Retrospective review of this data was performed. RESULTS: Fifty patients underwent rVHR during the study period. Median body mass index was 31 (interquartile range (IQR) 29-34). Forty-eight had previous abdominal surgery. Forty-seven hernias were midline and three were lateral. Regarding hernia width, 15 were <4 cm wide, 32 were 4-10 cm and three were >10 cm. Median total anaesthetic time, docking time and surgical console time were 214 min (IQR 182-252), 5 min (IQR 4-8) and 144 min (IQR 104-174), respectively. No major intra-operative complications occurred. No documented cases of adhesional complications or chronic post-operative pain have occurred. To date, two recurrences have occurred in our series. Median length of hospital stay was 3 days (IQR 2-4). CONCLUSION: We describe our rVHR technique and report on our series and early experience, showing that rVHR can be performed safely with good patient outcomes. We demonstrate a team approach to achieving a safe transition to new technology.

Day case hernia repair: weak evidence or practice gap?

BACKGROUND: Analysis of a private insurer's administrative data set revealed significant variation in the length of hospital stay following hernia surgery. OBJECTIVES: This review examined factors influencing the performance of day surgery for inguinal, femoral and umbilical hernia repair in adults. DATA SOURCES: A systematic literature search was conducted in the PubMed, Embase and Cochrane Library databases to identify studies and clinical practice guidelines (CPGs) comparing same day hernia surgery to surgery followed by an overnight stay. REVIEW METHODS: Screening of studies by abstract and full text was completed by a single researcher and checked by a second. Studies were selected for inclusion based on a step-wise approach across three phases. RESULTS: Limited evidence from one systematic review, and three case series studies including 3213 patients found that same day hernia surgery was as safe and effective as an overnight stay. All identified CPGs recommended a same day procedure for most patients. Two case series studies reported that 3-8% of patients were ineligible for day procedures due to medical reasons; however, the characteristics of patients, in general, which are not suitable, have not been adequately investigated. CONCLUSIONS: Day surgery for groin hernia repair is safe and effective for most patients. However, evidence-based support is only one of many factors that may contribute to the uptake of day surgery in Australia. There is an opportunity for key stakeholders across the private healthcare system to deliver an equally effective but more sustainable and affordable hernia care by increasing the day surgery rates.

Single port component separation: endoscopic external oblique release for complex ventral hernia repair.

BACKGROUND: Component separation (CS) is a technique which mobilizes flaps of innervated, vascularized tissue, enabling closure of large ventral hernia defects using autologous tissue. Disadvantages include extensive tissue dissection when creating these myofascial advancement flaps, with potential consequences of significant post-operative skin and wound complications. This study examines the benefit of a novel, ultra-minimally invasive single port anterior CS technique. METHODS: This was a prospective study of 16 external oblique (EO) releases performed in 9 patients and 4 releases performed in 3 fresh frozen cadavers. All patients presented with recurrent complex ventral hernias, and were administered preoperative Botulinum Toxin A to their lateral oblique muscles to facilitate defect closure. At the time of elective laparoscopic repair, patients underwent single port endoscopic EO release using a single 20-mm incision on each side of the abdomen. Measurements were taken using real-time ultrasound. Postoperatively, patients underwent serial examination and abdominal CT assessment. RESULTS: Single port endoscopic EO release achieved a maximum of 50-mm myofascial advancement per side (measured at the umbilicus). No complications involving wound infection, hematoma, or laxity/bulge have been noted. All patients proceeded to laparoscopic or laparoscopic-open-laparoscopic intraperitoneal mesh repair of their hernia, with no hernia recurrences to date. CONCLUSIONS: Single port endoscopic EO release holds potential as an adjunct in the repair of large ventral hernia defects. It is easy to perform, is safe and efficient, and entails minimal disruption of tissue planes and preserves abdominal wall perforating vessels. It requires only one port-sized incision on each side of the abdomen, thus minimizing potential for complications. Further detailed quantification of advancement gains and morbidity from this technique is warranted, both with and without prior administration of Botulinum Toxin A to facilitate closure.

A randomized double-blind clinical trial of a continuous 96-hour levobupivacaine infiltration after open or laparoscopic colorectal surgery for postoperative pain management--including clinically important changes in protein binding.

BACKGROUND: Continuous local anesthetic infiltration has been used for pain management after open colorectal surgery. However, its application to patients undergoing laparoscopic colorectal surgery has not been examined. The aim of this prospective, randomized, double-blind, placebo-controlled clinical trial was to study the use of a commercial infiltration device in patients undergoing open or laparoscopic colorectal surgery, along with plasma concentrations of levobupivacaine, its acute-phase binding protein (alpha-1 acid glycoprotein, AAG), and the stress marker, cortisol. METHODS: Eligible patients were randomized (2:1) to receive a continuous infiltration of either levobupivacaine or placebo using a commercial device (ON-Q PainBuster) inserted in the preperitoneal layer at the end of surgery. Blood was sampled for determination of levobupivacaine and AAG and cortisol concentrations. Other outcomes measured were pain scores, morbidity and mortality, time to bowel movement, mobilization, and length of hospitalization. RESULTS: In patients having open surgery, the levobupivacaine treatment showed a trend toward reduced total opioid consumption. No patients reported adverse effects attributable to levobupivacaine, despite 11 patients having concentrations at some time(s) during the 96-hour infiltration of up to 5.5 mg/L exceeding a putative toxicity threshold of 2.7 mg/L. AAG concentrations measured postsurgery increased by a mean of 55% (P < 0.001) at 48 hours. Cortisol concentrations also increased significantly by a mean of 191% at 1 hour. CONCLUSIONS: Continuous local anesthetic infiltration may be more beneficial in open surgery. The threshold for adverse effects from highly bound local anesthetic drugs established in healthy volunteers is of limited usefulness in clinical scenarios in which AAG concentration increases in response to surgical stress. Hence, there is scope to adopt higher doses to enhance therapeutic benefit.

Safety of 96-hour incision-site continuous infusion of ropivacaine for postoperative analgesia after bowel cancer resection.

The aim of this study was to examine the safety of ropivacaine given to patients as a continuous infusion [0.2% (2 mg/mL), 5 mL/h for 96 hours] into a right lateral transverse incision using a portable elastomeric infusion pump after colon cancer resection. Blood samples were collected throughout the infusion and up to 12 hours after infusion and were analyzed by high-performance liquid chromatography (HPLC) for total and unbound ropivacaine concentrations in plasma. Alpha1 acid glycoprotein (AAG) concentrations were measured at 0 and 48 hours to assess possible changes in ropivacaine protein binding after surgery. Postoperative pain control was assessed using 12 hour visual analog scale (VAS) scores. Patient-controlled analgesia (PCA) using fentanyl was freely available in parallel for breakthrough pain, with usage and consumption compared with a historical cohort. The mean +/- SD Cmax total plasma ropivacaine concentration (n = 5) from 12 hours to the end of the infusion was 4.5 +/- 2.6 mg/L, comparable with the previously published threshold for CNS toxicity in the most sensitive patient studied (3.4 mg/L). However, the corresponding maximum unbound ropivacaine concentration (ie, the pharmacologically active moiety) of 0.07 +/- 0.01 mg/L ranged from four- to sevenfold below the reported toxicity threshold (0.34 mg/L). The apparently greater safety margin seen with unbound ropivacaine may have resulted from a significant increase (mean 63%, P < 0.05) in AAG concentrations measured at 48 hours after surgery. This reduction resulted from the known AAG reaction after surgical intervention, resulting in a reducing unbound ropivacaine fraction throughout the 96 hour infusion in all patients. Mean subjective 12 hour pain scale scores at rest and on movement showed large variability between patients. No signs or symptoms of ropivacaine toxicity were observed or reported on questioning. In this limited sample, extending the infusion period from the presently approved 48 hours to 96 hours seems to be a safe alternative and/or adjunct to standard opiate analgesia after colorectal surgery using a right lateral transverse incision, hence reducing the incidence of opiate adverse effects and enhancing recovery. Unbound ropivacaine concentrations suggest there is scope for testing elevated doses to enhance efficacy further.