Abstract


Introduction: Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and earlier return to normal activity. Robotic surgery adds high definition visualization and articulating instruments. This enhanced dexterity can make laparoscopic hernia repair more refined while obtaining a critical view of the myopectineal orifice that should lead to fewer recurrences and complications. A series of robotic, laparoscopic, inguinal hernia repairs by a single surgeon with extensive laparoscopic hernia experience at a single institution along with a review of the literature was undertaken to determine the role of robotic laparoscopic inguinal hernia repair in minimally invasive surgery.
Materials and Methods: One thousand laparoscopic inguinal hernia operations were performed from April 2012 through March 2020. There were 420 cases of robotic trans-abdominal pre-peritoneal (TAPP) procedures done during that time. Hospital records and follow-up care were prospectively reviewed and data was collected for age, sex, American Society of Anesthesia (ASA) class, and operative time. Follow up was done at two weeks, eight weeks, and 16 weeks following surgery. All patients consented for study.
Results: Ninety-four percent (94%) of the patients were male. Age averaged 57.8 years with a range of 18–85 years. ASA averaged 2.01 with comorbidities of hypertension, hypercholesterolemia, and GERD being the most common. Body mass index (BMI) was between 19–40.5 averaging 26.6. Sixty-three patients (15%) had an umbilical hernia repair done concomitantly. Operating room (OR) time ranged from 25–140 minutes, with an average of 54.36 minutes, and decreased as experience increased. One patient with a large, left scrotal hernia was converted to open, one patient developed perforated sigmoid diverticulitis seven days postoperative and four recurred indirectly after a direct hernia repair. Urinary retention was the most problematic postoperative occurrence.
Conclusions: Robotic inguinal hernia repair is safe and effective. 1) Proper training, including simulators and proctors, is necessary; 2) having the same operating room team and an interested first assistant at the OR table is very helpful; 3) the learning curve is about 50 patients; 4) postoperative narcotics are rarely more than three hydrocodone pills; 4) no fixation of the mesh is necessary, but fibrin sealant was used routinely in these patients; and 5) urinary retention is the most common postoperative issue and is best planned for by knowing the patients urinary history, use of peripheral alpha-blockers, and straight catheterization in the OR at the conclusion of the surgery. OR time was longer than standard laparoscopic herniorrhaphy but decreased with experience. The robotic technique allowed for an excellent view of the myopectineal orifice and appears to have a low complication rate.

Abstract


This retrospective study reveals the results of our approach to the treatment of complex ventral hernias. A single-center, single-surgeon retrospective chart review on 68 consecutive patients who underwent abdominal wall reconstruction for incisional herniation on the midline between January 2012 and December 2016 is presented. The Bonheiden technique is based on anterior component separation in combination with preperitoneal retromuscular mesh reinforcement of the midline. Data of 68 consecutive cases of incisional midline abdominal wall defects treated electively with the mesh reinforced anterior component separation technique were analyzed. Demographics, patient characteristics, and hernia properties were evaluated. Postoperative complications included 28% of wound infections/dehiscence, 25% seromas, and 7% hematomas. No recurrences have been seen. We conclude this technique to be safe and reliable for large midline defects in patients suffering with several comorbidities.

Abstract


Ventral hernia repair is one of the most common operations performed by surgeons worldwide. The widespread adoption of laparoscopic surgery has significantly reduced complications related to traditional open approaches. The most common approach in laparoscopic ventral hernia repair is the intraperitoneal onlay mesh (IPOM) approach. This technique, though simple to perform, has limitations, including bridging mesh, intraperitoneal positioning of mesh, transfascial fixation, circumferential mesh fixation, and the use of more expensive composite mesh materials. These limitations are magnified when hernias occur in anatomically difficult sites such as the subxiphoid, suprapubic, and flank regions. Robotic-assisted hernia repair using a transabdominal preperitoneal (TAPP) approach has emerged as a viable alternative to traditional IPOM by potentially addressing these limitations. We review the operative considerations, intraoperative approach, and current body of literature related to robotic-assisted TAPP ventral hernia repair and conclude that it is feasible and may result in improved outcomes related to the restoration of abdominal wall anatomy and reduced operative costs. Further studies are needed to assess if robotic-assisted TAPP should become the standard approach for repair of ventral hernia defects.

Abstract


Introduction: While many scientific reports deal with inguinal hernia, including treatment methods and prosthetic devices proposed to provide a cure, few studies have sought to deepen our understanding of the etiology of this disease. The genesis of inguinal protrusion seems to be a neglected subject, even though addressing hernia genesis may be helpful for improving techniques and materials for surgical treatment. To clarify the source of inguinal protrusions, macroscopic and histological alterations of the inferior epigastric vessels in the herniated groin have been studied. These vascular structures exhibit significant features that could help to illuminate hernia genesis.
Material and methods: In patients with double ipsilateral inguinal hernia, composed of distinct direct and indirect protrusions, a tissue septum separates the two defects. Macroscopic observation and histological examination of this septal arrangement were carried out in 23 patients to highlight characteristics of the inferior epigastric vessels in the posterior aspect of this anatomical area.
Results: The examined inferior epigastric vessels presented notable alterations of the gross anatomy and histologically significant damage, with a typical trait of chronic compressive damage. All degrees of degeneration were observed, including complete disbanding of the vascular structure.
Conclusions: In pantaloon hernias, excised inferior epigastric vessels suffered from chronic compressive degeneration but had no contact with the protrusions. Therefore, protrusion expansion does not produce the degenerative injuries seen in the epigastric vessels. In the inguinal area, there is no source of chronic compression except visceral impact. Consequently, orthostatic visceral impact could be hypothesized to cause structural weakening of the groin, leading to tissue disbanding and visceral protrusion through the weakened inguinal floor.

Abstract


Introduction: The ideal fixation methods in laparoscopic ventral hernia repair continue to be debated. Early series touted the importance of suture and tack fixation; however, due to the perceived concern for increased pain, newer tack-only fixation methods have emerged. The purpose of this study was to compare fixation methods in laparoscopic ventral hernia repairs using a large hernia database.
Materials and Methods: We retrospectively reviewed data from the Americas Hernia Society Quality Collaborative (AHSQC) database comparing two groups of fixation (all tacks vs. all sutures and tacks and sutures and permanent tacks vs. sutures and absorbable tacks). The primary outcome measures were hernia recurrence, hospital length of stay, surgical site infection, surgical site occurrence, pain intensity scores, and quality-of-life scores evaluated at 30 days, six months, one year, and two years, Propensity score matching was used to strengthen the retrospective nature of the study.
Results: Eight hundred and fifty-two patients were included for analysis; 426 patients with tack-only fixation and 426 with tack and suture fixation. Eight hundred and four total patients were included for analysis; 402 patients with sutures with permanent tacks and 402 patients with sutures and absorbable tacks. For both comparisons, there was no significant difference in hospital length of stay, hernia recurrence rate, surgical site infection rate, surgical site occurrence rate, or surgical site occurrence requiring procedural intervention (p>0.05). There was also no significant difference in pain scores and quality-of-life scores at baseline, 30 days, six months, and one year. The only significant difference was in quality of life at two years. Patients with sutures and tacks had better quality-of-life scores compared with patients with tacks only (64 vs. 39, p<0.001).
Conclusion: Data available in the AHSQC database reviewed in this study indicate that there were no clinically significant differences between types of fixation methods when used in laparoscopic ventral hernia repair.

Abstract


Purpose: To investigate the safety and outcomes of laparoscopic control of intraperitoneal mesh positioning in open umbilical hernia repair.
Methods: This study is a retrospective review of a series of adult patients with uncomplicated umbilical hernia who underwent elective open repair with a self-expanding patch with laparoscopic control from March 2011 to December 2018. The adequacy of mesh positioning was inspected with a 5-mm 30° scope in the left flank. The primary endpoint was recurrence. Secondary endpoints were rate of mesh repositioning, intraoperative complications and time, length of stay and postoperative pain.
Results: Thirty-five patients underwent open inlay repair of primary umbilical hernia with laparoscopic control. Six patients (17.1%) were obese. The mean operating time was 63.3 min. The mean defect size was 2.6 cm (0.6-5) and the mean mesh overlap was 3.2cm (2.2-4.5). There were no intraoperative complications. Laparoscopic control required mesh repositioning in 5 cases (14.3%). The median length of stay was 2 days. Perioperative complications were recorded in three cases (8.6%): one seroma and two serous wound discharge (Clavien-Dindo I). The recurrence rate was 2.9% (1 case) at a median follow-up of 60 months. BMI>30 was associated with a higher rate of intraoperative mesh repositioning (p=0.001). Non-reabsorbable mesh and COPD were associated with a higher incidence of postoperative complications (p=0.043). Postoperative pain scores were consistently at mild levels, with no statistically significant differences between patients who had their mesh repositioned and those who had not.
Conclusions: Laparoscopic control of mesh positioning is a safe addition to open inlay umbilical hernia repair and enables the accurate verification of correct mesh deployment with low complication and recurrence rates.

Abstract


Background: Chronic pain still occurs in 10-12% of patients who undergo surgical groin hernia repair. Considering the high prevalence of this pathology, we performed a single-center prospective study comparing the laparoscopic trans-abdominal pre-peritoneal (TAPP) approach to the standard surgical open technique for primary uncomplicated hernia repair.
Methods: A prospective cohort of 278 patients was extracted from our dataset: 121 received a laparoscopic TAPP approach, and 157 were treated by the Lichtenstein technique in case of inguinal hernia or by the deployment of a polypropylene plug in case of femoral hernia. Both groups were followed-up for 3 years.
Results: A significant difference in haematoma/seroma collection was found (P=0.001) among the groups. Wound infection (P=0.001) and pain perception in the perioperative and early post-operative period were significantly reduced in the TAPP group (P=0.0023 and P<0.0021, respectively). Chronic discomfort at 3-year follow-up was higher in the open approach (P=0.0044), while operative time was marginally shorter compared to TAPP (P =0.002).
Conclusion: The incidence of chronic pain and the overall complication rate were significantly lower with the TAPP approach. Based on our findings, the TAPP approach deserves to be considered as the treatment of choice for uncomplicated single-site primary hernia surgery. Further studies with a larger sample will be needed to confirm these preliminary data.