Robotic transabdominal retromuscular umbilical prosthetic hernia repair (TARUP): observational study on the operative time during the learning curve.

PURPOSE: The use of extraperitoneal mesh in place of intra-peritoneal mesh is gaining popularity in laparoscopic ventral hernia repair. We have adopted a robotic assisted laparoscopic technique using a lateral single-dock robotic access with retromuscular mesh placement after opening the ipsilateral posterior rectus fascia. In this study, we wanted to evaluate the changes in operative times during the initial experience with this novel technique. METHODS: The initial consecutive patients undergoing robotic assisted transabdominal retromuscular umbilical prosthetic repair (r-TARUP) using a 15 × 15 cm self-fixating mesh were prospectively entered in the study and the operative times during the separate steps of the surgical procedure were recorded. Complications were reported up to 4 week post operatively and quality of life was assessed using the EuraHS-QoL score. RESULTS: Over a 5 month inclusion period, 41 patients with either a primary (n = 34) or a trocar site hernia (n = 7) at the umbilicus were identified. All hernias had a mean diameter of less than 4 cm. The total OR time decreased significantly during the learning curve (tertile 1: 126 min versus tertile 3: 102 min; p = 0.002) due to a decrease in the skin-to-skin operating time (tertile 1: 81 min versus tertile 3:61 min; p = 0.002). The decrease in the retromuscular dissection time was the most significant of all the steps that comprised the console time (p = 0.004). The non-surgical time did not decrease (p = 0.15). The operation was performed on an outpatient basis in 68% of patients and with a one-night-stay in 29%. No complications related to the introduction of the robotic technique for this approach were observed and the early outcome is promising, with favorable quality-of-life evaluation at 4 weeks. CONCLUSIONS: The decrease in operative time during the adoption of r-TARUP was mainly related to the improved efficiency in the dissection phase of the procedure. The technique is reproducible and safe and the operative time compares favorably to published operative times for laparoscopic and open retromuscular umbilical hernia repair.

The use of cyanoacrylate sealant as simple mesh fixation in laparoscopic ventral hernia repair: a large animal evaluation.

PURPOSE: The use of glue as mesh fixation in laparoscopic ventral hernia repair (LVHR) significantly reduces fixation associated morbidity. This experiment evaluates the intraperitoneal use of synthetic glue as single mesh fixation. METHODS: A total of 21 sheep were operated using a hernia model with two fascial defects of 2 cm(2) at the linea alba. One week later two polypropylene meshes (Dynamesh®) were implanted laparoscopically, using cyanoacrylate glue (Ifabond®) or conventional fixation (Securestrap®). In half of the animals the fascial defect was closed before mesh placement. After 1 day (n = 6), 2 weeks (n = 8) and 6 months (n = 6), a second laparoscopy was performed at which hernia recurrence, mesh integration and adhesion formation were evaluated. After euthanasia, burst strength testing and histopathology were evaluated. RESULTS: One animal died due to intestinal incarceration. In 20 surviving animals, no hernias were diagnosed and mesh placement was satisfying. Adhesions could hardly be observed after 1 day but were omnipresent in both groups at 2 weeks and 6 months. Burst strength testing exceeded 100 N in all samples, independent of the fixation device used. Not after 1 day, but after 2 weeks the inflammatory cell response was significantly higher in the glue group. At 6 months minor inflammation was seen, as was foreign body reaction (FBR). CONCLUSIONS: Using a standardized biomechanical testing system, synthetic glue can be considered an effective fixation tool in LVHR. The possible tissue toxicity of cyanoacrylates does not lead to an increased FBR. No difference in burst strength was observed for closing or not closing the defect.