Primary Fascial Closure During Minimally Invasive Ventral Hernia Repair

Bernardi, Karla; Olavarria, Oscar A.; Liang, Mike K.

doi:10.1001/jamasurg.2019.5088

Cited by 8 publications

(7 citation statements)

References 8 publications

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“…Intracorporeal suturing allows for closure of the fascial defect with a running self-locking suture, a practice associated with improved quality of life (QoL) and reduced recurrence for laparoscopic closures with the shoelacing technique …”

Section: Introductionmentioning

confidence: 99%

“…[16][17][18] Introduction of the robotic platform allows for several potential advantages vs the traditional laparoscopic approach when repairing a ventral hernia with intraperitoneal mesh 19 : • Intracorporeal suturing allows for closure of the fascial defect with a running self-locking suture, a practice associated with improved quality of life (QoL) and reduced recurrence for laparoscopic closures with the shoelacing technique. 20,21 • Peritoneal mesh fixation with a running stitch as opposed to tacks and transfascial sutures often implicated as a source of postoperative pain following laparoscopic repairs. 17,22 Here, we hypothesized that the robotic approach to ventral hernia repair with intraperitoneal mesh would provide a measurable clinical benefit in regards to early postoperative pain compared with the traditional laparoscopic approach.…”

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confidence: 99%

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Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh

et al. 2020

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IMPORTANCE Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.OBJECTIVE To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain. DESIGN, SETTING, AND PARTICIPANTSA registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.INTERVENTIONS Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh. MAIN OUTCOMES AND MEASURESThe trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost. RESULTSSeventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).CONCLUSIONS AND RELEVANCE Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.

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Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh

et al. 2020

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“…When technically feasible, primary fascial closure should be performed before mesh placement, with the intent of placing the abdominal wall muscles under the physiological tension needed for optimal function [11].…”

Section: Large Bowel Obstruction Due To Incarcerated Spigelian Hernia...mentioning

confidence: 99%

“…Since no unequivocal recommendation exists, circumferential fixation is advised, and the use of non-absorbable tacks should be preferred in terms of cost and rate of recurrence compared to absorbable tacks[10].When technically feasible, primary fascial closure should be performed before mesh placement, with the intent of placing the abdominal wall muscles under the physiological tension needed for optimal function[11].SH is named after the Flemish anatomist Adrian van der Spieghel, who was the first to describe the linea semilunaris (now known as the linea Spigeli) in 1645[1][2][3]. Interestingly, he never described this type of hernia, which was recognized by Beatricio Ignatius La Chausse and Josef Klinklosch more than a century later[1,2].…”

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confidence: 99%

Large bowel obstruction due to incarcerated Spigelian hernia: a video vignette of laparoscopic mesh repair

2020

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“…In the Surgical Innovations article, “Primary Fascial Closure During Minimally Invasive Ventral Hernia Repair,” published online December 26, 2019, an error appeared in the text. The 95% CI of a relative risk for a study by Ahonens et al was misreported as 2.8 to 13.3.…”

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2020

JAMA Surg

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In Reply We appreciate the interest in our article and thank JAMA Surgery for the opportunity to reply to the letters to the editor. 1 Shi et al advised that combining patients without postoperative pancreatic fistula (POPF) and with biochemical leakage may have biased the analysis regarding long-term survival in patients receiving neoadjuvant therapy (NAT). While biochemical leakage may reflect a more preserved gland function, which has been associated with better survival in upfront resected pancreatic cancer, 2 a preliminary analysis had shown no significant differences between biochemical leakage and no pancreatic fistula in patients with NAT. The use, assessment, and prevalence of soft pancreatic texture faced criticism. Regarding the description of gland texture as assessed by the surgeon's manual palpation, this method has been recognized as noninferior to technical measurements. 3 The subjective approach is indeed widely used in most POPF prediction metrics. We agree with Trudeau and Vollmer that the soft pancreas has not been confirmed to be a determinant of POPF after distal pancreatectomy, and that a separate analysis of risk factors in proximal and distal resections would have been advisable. Owing to the overall low incidence of CR-POPF in patients with NAT, which was less than 5%, a specific analysis for distal resections was not feasible. Nonetheless, soft pancreatic texture was the only risk factor associated with the occurrence of CR-POPF after pancreatoduodenectomy in patients with NAT. Despite a lack of specific pathological assessment, our hypothesis of NAT-related fibrotic deposition and desmoplastic remodeling of the gland is based on previous strong pathologic evidence. 4 In their letter, Trudeau and Vollmer stressed how blood loss is a crucial determinant of surgical outcomes, and specifically CR-POPF. This appeared to be even more important in the setting of NAT, as they observed that preoperative systemic treatment was a major risk factor for increased intraoperative blood loss. 5 In their study with data from 17 institutions and more than 5300 patients, only 29 (1.8% of patients with cancer) received NAT, and therefore definite conclusions cannot be drawn. Furthermore, other large studies in patients undergoing pancreatoduodenectomy have failed to validate the association between blood loss and POPF, and in fact the Dutch group proposed an alternative fistula risk score that does not include blood loss. 6 In conclusion, no studies have specifically addressed the determinants of CR-POPF in the setting of NAT, and consequently the broad application of prediction metrics developed for treatment-naive patients might be misleading in this context. As well pointed in the last comment, our cohort of upfront resected patients included mainly resectable tumors, as well as some borderline resectable that underwent upfront resection and associated vascular resection. However, we believe that this aspect does not limit the observed adverse survival effect of CR-POPF in the NAT cohort nor the streng...

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Primary Fascial Closure During Minimally Invasive Ventral Hernia Repair

Cited by 8 publications

References 8 publications

Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh

Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh

Large bowel obstruction due to incarcerated Spigelian hernia: a video vignette of laparoscopic mesh repair

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