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Robotic inguinal hernia repair: Is it a new era in the management of inguinal hernia?

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Objective We compared outcomes of elective inguinal hernia repair performed at one institution by three approaches: robotic-assistance, laparoscopic, and open. Methods Characteristics of the patients, the hernia and the procedures performed during 2014–2016 were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries were robotic-assisted, 16 laparoscopic and 97 open repairs. Results Distributions of age, sex and BMI did not differ between the groups. Bilateral repair was more common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p < 0.001). Direct hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups (p < 0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p < 0.001). Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for 2–3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this difference was not statistically significant. The median maximal postoperative pain according to a 0-10-point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respectively (p < 0.001). Conclusions This report demonstrated the safety and feasibility of robotic-assisted inguinal hernia repair.
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Original article
Robotic inguinal hernia repair: Is it a new era in the management of
inguinal hernias?
Eli Kakiashvili
a
,
b
,
*
, Maxim Bez
c
, Ibrahim Abu Shakra
a
, Samer Ganam
a
, Amitai Bickel
a
,
b
,
Fahed Merei
a
, Assi Drobot
a
, Grigori Bogouslavski
a
, Walid Kassis
a
, Kamal Khatib
a
,
Mahran Badran
a
, Yoram Kluger
d
, Ronit Almog
e
a
Department of Surgery A, Galilee Medical Center, Nahariya, Israel
b
Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
c
Medical Corps, Israel Defense Forces, Ramat Gan, Israel
d
Department of General Surgery, Rambam Medical Center, Haifa, Israel
e
Director of Epidemiology Unit, Rambam Medical Center, Haifa, Israel
article info
Article history:
Received 18 November 2019
Received in revised form
9 March 2020
Accepted 23 March 2020
Available online xxx
abstract
Objective: We compared outcomes of elective inguinal hernia repair performed at one institution by
three approaches: robotic-assistance, laparoscopic, and open.
Methods: Characteristics of the patients, the hernia and the procedures performed during 2014e2016
were accessed from patient electronic medical les of 137 elective inguinal hernia repairs. 24 surgeries
were robotic-assisted, 16 laparoscopic and 97 open repairs.
Results: Distributions of age, sex and BMI did not differ between the groups. Bilateral repair was more
common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p <0.001). Direct
hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups
(p <0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times
were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p <0.001).
Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic
procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for
2e3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this dif-
ference was not statistically signicant. The median maximal postoperative pain according to a 0-10-
point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respec-
tively (p <0.001).
Conclusions: This report demonstrated the safety and feasibility of robotic-assisted inguinal hernia
repair.
©2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
1. Introduction
Inguinal hernias account for 75% of all abdominal wall hernias;
the lifetime risk is 27% in men and 3% in women. Repair of these
hernias is one of the most common surgical procedures in the
world.
1
In the United States, approximately 800,000 inguinal hernia
repairs are performed annually.
2
Historically, hernias have been documented dating back to the
ancient Greco-Roman period. Since then, treatment of groin hernias
has evolved through 6 major eras.
3e5
The rst era takes us to the
Egyptian papyrus Ebers period, during which the hernia was
described as a swelling that comes out when one coughs.The
second era began in the Renaissance, during which the knowl-
edge of surgical anatomy increased substantially. The treatment,
however, was limited to life threatening disease such as incarcer-
ated hernias. In the third era, anesthesia and aseptic technique
advanced hernia surgery. This was evidenced by signicantly lower
complications, but recurrence rates remained at 100% at four years.
The 19th to mid-20th century gave rise to the fourth era, during
*Corresponding author. Department of Surgery A, Galilee Medical Center,
Nahariya, Israel.
E-mail addresses: elik@gmc.gov.il (E. Kakiashvili), ibra89him.abushakra@gmail.
com (I. Abu Shakra).
Contents lists available at ScienceDirect
Asian Journal of Surgery
journal homepage: www.e-asianjournalsurgery.com
https://doi.org/10.1016/j.asjsur.2020.03.015
1015-9584/©2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Asian Journal of Surgery xxx (xxxx) xxx
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
which repair was performed under tension with the reconstruction
of the posterior wall of the inguinal canal, pioneered by Bassini and
Shouldice. The fth era marked repair without tension with the use
of prosthetic materials pioneered by Lichtenstein. Over 1000 cases
of this type of repair were published and demonstrated no re-
currences at 5 years. The sixth era started in 1979 when P. Fletcher
introduced the laparoscopic technique for the management of
inguinal hernia. In the 1990s, the two main techniques for laparo-
scopic hernia repair were developed and rened: the trans-
abdominal pre-peritoneal (TAPP) approach and the totally extra-
peritoneal (TEP) approach. Neither technique has been demon-
strated as superior. Both TAPP and TEP have similar operative times,
post-operative pain, the timing of return to work and
recurrences.
8,9
Open, mesh-based, tension-free repair remains the standard
technique for laparoscopic hernia repair. Performed by adequately
trained surgeons, the results are excellent, and comparable to those
of open repair.
6,7
Laparoscopic inguinal hernia repair has certain
advantages over open repair including reduced postoperative pain,
a diminished requirement for narcotics, and earlier return to work
and normal activities.
8e12
Disadvantages of laparoscopic repair
include increased costs, longer operating room time, a steeper
learning curve, and higher recurrence and complication rates early
in a surgeon's experience. Importantly, a prolonged learning curve
has limited more generalized application of a minimally invasive
approach in the management of groin hernias.
Robotic-assisted surgery is well established as a technique that
provides improved three-dimensional visualization and enhanced
dexterity with articulating instrumentation. However, its applica-
tion and true benet in general surgery, and in groin hernia surgery
in particular is still under investigation. Relative contraindications
to robotic-assisted surgeries include: previous laparoscopic repair,
ascites, peritoneal dialysis and large inguinoscrotal hernias.
13
Other
strong contraindications for minimally invasive inguinal hernia
repair include multiple previous abdominal surgeries, the inability
to tolerate pneumoperitoneum and a grossly contaminated
abdominal cavity that would preclude the use of a mesh.
In this study we present the initial experience of robotic inguinal
hernia repair performed by one surgeon at a single institution. The
aim is to demonstrate the feasibility and safety of the robotic
approach. All the robotic procedures were compared to traditional
open and laparoscopic inguinal hernia repairs performed in the
same institution during the same period by different surgeons. The
goal of the comparison was to determine whether robotic assis-
tance confers a benet and superiority over the other two ap-
proaches, and may thus be expected to dominate minimally
invasive inguinal hernia repair in the future.
2. Methods
2.1. Patient selection
We reviewed the electronic medical les of all the patients who
underwent elective surgery due to an inguinal hernia at Rambam
Health Care Campus, Israel, during the period 2014 to 2016 by a
single surgeon with over 15 years of experience in open and lapa-
roscopic hernia repair and approximately 200 major oncologic
surgeries using robotic assistance. Inclusion criteria were: age18 ,
a uni/bilateral inguinal hernia, a direct/indirect hernia, and rst or
recurrent inguinal hernias. For each patient we collected informa-
tion on age, sex, BMI, hernia characteristics: type (indirect/direct/
both), laterality (unilateral/bilateral), inguinoscrotal (yes/no),
recurrent (yes/no). Operative procedure details included: type
(open/laparoscopic/robotic), TAPP/TEP, and the operation time. The
latter was dened as the time between start of the surgery (rst
incision) and the nish of surgery (closure of the skin). Post-
operative discharge days of hospitalization (POD) were calculated
as the difference between the operation date and the discharge
date. POD was analyzed as a dichotomous variable: 1 day and >1
day, as the vast majority of patients were hospitalized for 1 day.
Postoperative pain was assessed by 2 measures: maximal post-
operative Visual Analogue Scale (VAS) measurement (on a scale of
0e10, with 10 representing the maximum pain) and the mean
number of times that analgesic drugs were dispensed to patients
during the 24-h postoperative period. The drugs that were
considered were opioid and non-opioid analgesics, including ATC
third level code N02A and N02B. The most common drugs that
were used were dipyrone, paracetamol, oxycodone and tramadol.
2.2. The robotic-assisted surgical technique
All robotic cases were operated using the da Vinci Si surgical
platform. We employed three robotic arms: one for the camera and
two for robotic instruments. The camera port (12 mm) is placed at
the supra-umbilical area. We used a zero-degree camera, which
enables full and adequate visualization. Two other robotic ports
(8 mm) are localized 9 cm from the umbilicus (each site) at the level
of the umbilicus. We usually use one assistant port (10 mm) localized
in the right lower quadrant, which allows mesh and needle place-
ment into the abdominal cavity (Fig. 1). Our patient's position of
choice during operation is supine lithotomy with complete Trende-
lenburg. The robot is docked between the patient's legs (Fig. 2).
We prefer performing robotic inguinal hernia repair through the
TAPP approach. The relevant inguinal anatomy in this approach is
differentthan in the open or TEP approach. The importantanatomical
landmarksin the peritoneal cavityare: the medial umbilical ligament,
the internal inguinal ring and the inferior epigastric vessels.
Fig. 1. Placement of ports during robotic assisted inguinal hernia repair.
port placement: C- camera port, R1 and R2-robotic ports, A - assistant port.
E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx2
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
A curvilinearperitoneal incision is performed with the robotic hot
shears between the anterior superior iliac spine and the medial um-
bilicalligament, abovethe internal inguinalring. An incisionis created
that will enablesdissection of Cooper'sligament and a peritonealap,
and that accommodates the appropriate sized meshcomfortably. The
pre-peritoneal fat can be dissected bluntly and with modest use of
cautery, with care not to injure the inferior epigastric vessels. Visu-
alizationof these vessels is mandatory todetermine the type of hernia
(medial to the vessels is a direct hernia, and lateral to the vessels is an
indirecthernia). Ideally, the peritoneal ap shouldtsnugtothemesh
without mesh rolling.This also prevents mesh migration, which is
critical in the early period after repair.
Dissecting Cooper's ligament, just lateral to the symphysis pu-
bis, immediately after creating the peritoneal ap, usually facili-
tates recognition of the pre-peritoneal anatomy. Our practice is to
dissect and identify Cooper's ligament rst, before addressing the
rest of the dissection. Having Cooper's ligament in view serves as a
useful landmark, especially when the hernia sac is large and ob-
scures the eld of dissection. Once Cooper's ligament is identied, a
lateral dissection of the pre-peritoneal space is required, thus
leaving the hernia sac dissection until the end, and facilitating
identication of the spermatic cord, the vas deferens and the tri-
angle of doom (Fig. 3).
The hernia sac must be detached completely from the spermatic
cord to avoid seroma formation and hernia recurrence. In cases of
very large hernia sacs, such as inguinoscrotal hernias, in which
dissection may become challenging, the sac may be transected and
left in place. Caution should be taken to close the peritoneal defect
once the inguinal repair is completed.
According to the guidelines of the International Endohernia
Society, the recommended mesh size is 10 15 cm.
14
In all robotic
cases we used the 15/10 cm laparoscopic Progrip self-xating mesh
(Medtronic, Minneapolis, MN), which comprises anatomical
monolament polyester with absorbable polylactic acid grips and
absorbable collagen lm. The important sites for xating the mesh
are: Cooper's ligament, the rectus abdominis muscle (medial to the
inferior epigastric vessels) and the transverse abdominis fascia,
slightly lateral and above the internal inguinal ring.
During bilateral inguinal hernia repair, we create two distinct
peritoneal incisions that form two peritoneal aps on either side.
Fig. 2. Patient in the lithotomy position and robot docking.
Fig. 3. The right inguinal region in robotic-assisted inguinal hernia repair.
1) supravesical fossa, 2) Cooper's ligament, 3) inferior epigastric vessels, 4) transverse
arch, 5) vas deferens, 6) cord elements with gonadal vessels, and 7) peritoneal ap, the
triangle of doom (solid lines), the triangle of pain (dashed lines).
E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx 3
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
This has been shown to be more than adequate for the dissection.
At the end of the hernia repair, the peritoneum is closed with
barbed sutures (V-Loc 3e0, Medtronic, Minneapolis, MN). This re-
duces operating time signicantly and may also cause less post-
operative pain than surgical tackers.
2.3. Laparoscopic and open surgical technique
For TAPP repair, a supra-umbilical incision is made to access the
peritoneal cavity and a 10e12 mm trocar placed, and two 5-mm
ports either in the midline below the umbilicus or in the mid-
clavicular line bilaterally. The hernia is visualized by a 30 degree-
angle laparoscope. The inferior epigastric vessels, the spermatic
vessels, and the vas deferens should be identied, the peritoneum
is incised several centimeters above the myopectineal orice, from
the edge of the medial umbilical ligament laterally toward the
anterior superior iliac spine. The peritoneum is dissected off the
transversus abdominus and transversalis fascia until the pubis,
Cooper's ligament, and iliopubic tract are identied. An indirect
hernia sac is usually found on the anterolateral side of the cord. The
vas deferens and spermatic vessels are isolated and dissected free
from the surrounding tissues circumferentially, creating a window
inferiorly, to allow for passage of the mesh. At the end of the hernia
repair, the peritoneum is closed by absorbable barbed suture (V-Loc
3e0, Medtronic, Minneapolis, MN).
For Laparoscopic TEP, the port placement is similar to that for a
TAPP repair, except all ports are placed in the preperitoneal space.
The rst 10e12 mm port is placed using an open technique. A sub-
umbilical skin incision is made and then advanced slightly off the
midline, in front of the anterior rectus sheath. The anterior sheath is
opened transversely and the rectus muscle is swept laterally and
retracted anteriorly. The posterior rectus sheath is seen and left
intact. The 10-mm balloon-tip port is then inserted bluntly into the
preperitoneal space and inated. A 10-mm, 30-angle laparoscope is
placed and used to bluntly dissect the tissue in the preperitoneal
space. The preperitoneal space is dissected laterally to the anterior
superior iliac spine in order to place the 5-mm ports. The inferior
epigastric vessels, the pubic bone, and Cooper's ligament are
identied. Cooper's ligament is exposed, a direct hernia, if present,
will generally be reduced and a pseudosac may be found. Indirect
hernia sacs are managed the same as for TAPP repairs. Cord lipomas
are usually found laterally along the spermatic vessels and should
be reduced. Mesh placed is the same as for a TAPP procedure.
The Bassini repair is performed by suturing the transversus
abdominis and internal oblique musculoaponeurotic arches or
conjoined tendon (when present) to the inguinal ligament.
2.4. Statistical analysis
The chi square test and Fisher's exact test were performed to
determine signicant differences in categorical variables between
the 3 hernia repair procedures: open, laparoscopic and robotic.
ANOVA and the non-parametric KruskaleWallis tests were used to
compare continuous variables according to data distribution. Sta-
tistical signicance was dened as a two-tailed test with P <0.05.
All analyses were performed using SPSS software, version 21.
3. Results
Overall, 137 patients who underwent elective inguinal hernia
repair during the study period were included in the cohort. Of
them, 97 underwent open repair, 24 robotic repair and 16 laparo-
scopic repair. Table 1 compares demographic and clinical charac-
teristics and compares between the three procedure groups. No
signicant differences were found in age, sex or BMI between the
groups. Bilateral repair was more common in the robotic (70.8%)
than the laparoscopic (50.0%) and open groups (12.4%) (p <0.001).
Direct hernias were more common in the open (45.4%) than the
robotic (20.8%) and laparoscopic (12.5%) groups (p <0.001). Only 3
hernias were inguinoscrotal hernia, all of them in the robotic group.
Nine (56.3%) of the 16 laparoscopic repairs were performed ac-
cording to the TAPP method.
Table 2 presents the operative and postoperative outcomes by
operation type. Operation time signicantly varied between the
three operation methods. Median operation times were 44.0, 79.0
and 92.5 min for the open, laparoscopic and robotic methods,
respectively (p <0.001). The operative time did not differ signi-
cantly between the laparoscopic and robotic repair techniques.
Among the bilateral repairs, the relative differences in median
operative times remained: 67.5, 89.0 and 105.0 min, respectively,
for the three procedures. Among the unilateral repairs, the median
operative times were the same for the robotic and laparoscopic
procedures, 73 min, and less for the open procedures, 40 min. The
proportion of patients hospitalized for 2e3 days was higher for
open repair (13.4% vs. 6.2% and 0% forlaparoscopic and robotic), but
this difference was not statistically signicant. The median of
maximal postoperative pain according to the VAS was 5, 2 and 0 for
open, laparoscopic and robotic procedures, respectively (p <0.001).
The median number of analgesics during the rst 24 h post-
operative was signicantly higher following open compared to
laparoscopic and robotic procedures: 3.0, 1.5, 1.5, respectively
(p <0.001).
4. Discussion
The results of the present study indicate that robotic hernia
repair is feasible for all types of hernias (bilateral, recurrent, direct
and indirect, and inguinoscrotal) and for patients with various
characteristics. Postoperative discharge days and analgesic con-
sumption were similar following robot-assisted and laparoscopic
repair. For these measures, robotic and laparoscopic approaches
fared better than open procedures. This corroborates previous
knowledge of differences between open and laparoscopic repair.
More than 75% of the patients who underwent robotic repair re-
ported VAS 0 in all their measurements and this was signicantly
different from the open and laparoscopic groups. However,
reporting bias should be considered, since patients and staff were
not blinded regarding the procedure type or the surgeon's experi-
ence. Operation time was similar between laparoscopic and robotic
procedures for unilateral and bilateral repair.
Several studies have demonstrated a denite advantage of
laparoscopic repair over open repair with regard to reduced post-
operative pain and earlier return to work and normal activities.
15e18
Laparoscopic repair also offers clear advantage in bilateral and also
recurrent inguinal hernia repairs.
19,20
Another major advantage of
the laparoscopic approach is the ability to detect and repair a
contralateral defect during the same operation, with only a mod-
erate increase in operating time.
21
More recently, minimally inva-
sive surgery can be performed using robotic technology with
potential benets of enhanced visualization and improved dexter-
ity due to wristed instruments.
22
The rst robotic-assisted TAPP inguinal hernia repair procedures
reported herein implemented a technique that was similar to
laparoscopic TAPP inguinal hernia repair, including port posi-
tioning.
23,24
The initial procedures showed the need for technical
modications to prevent the robotic arm from clashing, and to
improve visualization and access to both groin sides. It was also
noted that placement of the mesh and sutures after docking would
increase the time of operation signicantly since it would require
undocking a robotic arm to place them inside the abdomen. After
E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx4
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
the initial 10 cases, the appropriate technical modications were
applied. The nal technical modications that were applied to the
last 10 cases decreased the time of operation substantially and
improved visualization and access to both sides of the groin, and
minimized robotic arm clashing. The time of operation for the last
robotic procedures that were performed according to the nal
standardized technique (as described earlier) at the end of the
study was comparable to that of the laparoscopic approach.
This report demonstrated the safety, feasibility and reproduc-
ibility of the robotic-assisted TAPP inguinal hernia repair in selected
patients by an experienced surgeon. Robotic technology enables
the surgeon to offer minimally invasive inguinal hernia repair to
patients with higher BMI and larger hernias, which are technically
more challenging using the laparoscopic approach.
25
Performing
robotic-assisted TAPP inguinal hernia repair safely and efciently
requires a long learning curve. However, for surgeons with
advanced laparoscopic skills, and with the adoption of measures
outlined in this report, this learning curve may become shorter. We
believe that an experienced surgeon with accessibility to advanced
robotic technologies, such as the da Vinci surgical platform, may
feel condent in performing more complex cases, such as ingui-
noscrotal hernias. This could consequently expand patient
selection, which in itself could increase the number of patients who
may benet from minimally invasive inguinal hernia repair.
5. Conclusions
Robotic inguinal hernia repair is a feasible and safe procedure.
The operative time is signicantly longer than for laparoscopic and
open techniques, and the additional costs are substantial. With the
adoption of the measures and the technique outlined in this report,
we believe it is feasible to shorten the operative time and the
surgeon's learning curve. Whether robotics may improve the out-
comes of minimally invasive inguinal hernia repairs, including
lowering recurrence rates, and decreasing postoperative pain, will
require future prospective investigation. If this will prove true, we
can say that there is a new era in the surgical management of
inguinal hernia.
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Table 1
Patient characteristics by procedure type.
Total (N ¼137) Open (N ¼97) Laparoscopic (N ¼16) Robotic (N ¼24) P value
Age, median (IQR) 55.0 (36.5e68.5) 55.0 (35.0e68.5) 48.0 (27.5e65.7) 60.0 (42.2e67.7) 0.876
Male 133 (97.1%) (96.9%) 94 (100%) 16 (95.8%) 23 1.0
Female (2.9%) 4 (3.1%) 3 0 (4.2%) 1
BMI, median (IQR) 26.0 (24.3e28.6) 26.0 (24.3e29.0) 26.0 (27.0e24.4) 25.6 (23.1e27.8) 0.523
Bilateral (27%) 37 (12.4%) 12 (50%) 8 (70.8%) 17 0.001>
Unilateral (73%) 100 (87.6%) 85 (50%) 8 (29.2%) 28
Hernia type 0.001>
Direct (37.2%) 51 (45.4%) 44 (12.5%) 2 (20.8%) 5
Indirect (57.7%) 79 (52.6%)51 (87.5%) 14 (58.3%) 14
Mixed type 7 (5.1%) 2 (2.1%) 0 5 (20.8%)
Surgical technique Bassini (100%)
a
0.001
TAPP Not relevant 9 (56.3%) 24 (100%)
TEP Not relevant 7 (43.8%) 0
Inguinoscrotal (2.2%) 3 0 0 (12.5%) 3 0.006
Recurrent hernia (3.6%) 5 (3.1%) 3 0 (8.3%) 2 0.305
a
Fisher's exact test between Laparoscopic and Robotic groups.
Table 2
Operative and postoperative outcomes according to operation type.
Operation time minutes median (IQR) Open Laparoscopic Robotic Total P value
Overall 44.0 (30.0e57.5) 79.0 (66.0e102.5) 92.5 (76.2e128.0) 55.0 (36.0e81.0)
a
0.16
b
<0.001
Bilateral repair 67.5 (55.8e100.5) 89.0 (66.0e103.8) 105.0 (86.5e134.5) 95.0 (70.0e117.0)
a
0.054
b
0.005
Unilateral repair 40.0 (29.0e53.0) 73.0 (60.3e98.5) 73.0 (59.0e75.0) 44.0 (30.0e61.3)
a
0.60
b
<0.001
POD
1
2-3
84 (86.6%)
13 (13.4%)
15 (93.8%)
1 (6.2%)
24 (100%)
0 (0%)
123 (89.8%) 14 (10.2%)
a
0.14
b
0.066
Max VAS during hospitalization Median (IQR) 5.0 (3.5e6.0) 2.0 (0e3.75) 0 (0e0) 4.0 (2.0e6.0)
a
0.01
b
<0.001
Analgesics (per day) Median (IQR) 3.0 (2.0e3.0) 1.5 (1.0e2.0) 1.5 (1.0e2.0) 2.0 (2.0e3.0)
a
0.48
b
<0.001
a
Comparison between laparoscopic and robotic surgery.
b
Comparison between open, laparoscopic and robotic surgery
E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx 5
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
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E. Kakiashvili et al. / Asian Journal of Surgery xxx (xxxx) xxx6
Please cite this article as: Kakiashvili E et al., Robotic inguinal hernia repair: Is it a new erain the managementof inguinal hernias?, Asian Journal
of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.015
... The surgical repair of inguinal hernia defects has evolved in parallel with the exponential growth of surgery as an academic discipline, catalyzed by the advent of anesthesia and aseptic technique in the mid-1800s [1]. Complication rates significantly decreased in the wake of this development; however, long-term integrity of inguinal hernia repairs remained unobtainable, with recurrence rates at 100% at 4-year follow-up [2]. While the Bassini, McVay and Shouldice methods of primary tissue repair serve as an operative tool in the setting of contamination where mesh placement is contraindicated [3], open tension-free repair using synthetic mesh as pioneered by Lichtenstein provided a robust framework for the development of modern techniques. ...
... While the Bassini, McVay and Shouldice methods of primary tissue repair serve as an operative tool in the setting of contamination where mesh placement is contraindicated [3], open tension-free repair using synthetic mesh as pioneered by Lichtenstein provided a robust framework for the development of modern techniques. Over 1000 cases using this technique were published, showing no recurrences at 5 years [2]. The modern era of minimally invasive inguinal hernia repair began with the introduction of laparoscopic techniques, namely trans-abdominal pre-peritoneal repair (TAPP) and totally extraperitoneal repair (TEP). ...
... The recurrence rate in the Kakiashvili study was 8.3%, which is higher than that of the open and laparoscopic rates in the same study (3.1% and 0%) [2]. Another study analyzing short-term outcomes from 22 surgeons using the TEP procedure found a 0.8 percent recurrence rate at 3 months with a sample size of 665 patients [7]. ...
Article
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There is a tremendous paucity of literatures regarding the long-term surgical outcomes of the r-TAPP procedure for inguinal hernia repair. Additionally, much of the existing literatures regarding this procedure have limited follow-up of to 12 months. This article presents the outcomes of 150 consecutive r-TAPP inguinal hernia repairs performed on 111 patients using Progrip mesh without fixation, with up to 24 months of follow-up. The initial 150 consecutive r-TAPP inguinal hernia repairs were performed from February 2017 to April 2018 using Progrip without fixation. All patients were seen at 2 weeks, followed by phone follow-up at 6 months, 1 year, and 2 years. Of the 111 patients, 39 had bilateral hernias (35%) and 72 had unilateral hernias (65%). The age range was 18–93 years. The BMI range was 20.7–50.2, with a mean of 26.4 and median of 25.8. Total operative time ranged from 28 to 138 min with a mean of 62.4 min and median of 56 min. ASA classification ranged from 1 to 4, with a mean of 2.1. No significant blood loss was observed in any of the cases. There were no conversions to open surgery. All patients were discharged the same day of the operation. We were able to follow up with 100% of the hernias at 2 weeks, 88% at 6 months, 87% at 1 year, and 80% at 2 years. No recurrences were recorded at 2 weeks, 3 months, 6 months, 1 year, or 2 years. There were no reports of chronic pain up to 2 years in any of the patients. These results indicate that r-TAPP inguinal hernia repair using Progrip without further fixation is safe, effective, and can be performed with minimal recurrences or chronic pain.
... Over the past decade, utilization of RHR has rapidly expanded in the United States, and continued growth is projected [18]. At present, there is significant variability in the results of 30-day post-operative outcomes between these techniques, and RHR has not consistently shown superior clinical outcomes compared to OHR and LHR [19][20][21][22][23][24]. Moreover, RHR is significantly more expensive on a percase basis, in addition to high installation costs [21,25,26]. ...
... OHR, the most utilized approach for herniorrhaphy in the VA, showed superior operative time, LOS, and complication rates in direct comparison with RHR. These two modalities have been thoroughly compared in the literature with mixed findings [19,20,22,24,41,42]. Huerta et al. [24] reported that OHR had lower incidence of complications versus RHR or LHR. ...
... Notably, in our study population, 23.3% of the OHR cases were performed without the use of general anesthesia, which could certainly explain why composite pulmonary complications were lower in this group. OHR was also found to be associated with shorter operative time compared to laparoscopic and robotic approach in several studies [19,22,41]. The robotic approach requires additional time to position the console and arms, as well as safe entry into the abdominal cavity. ...
Article
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PurposeRobotic inguinal hernia repair (RHR) is an evolving technique but is comparatively expensive and has yet to show superior outcomes versus open (OHR) or laparoscopic (LHR) approaches. The utilization and clinical outcomes of RHR have not been reported within the veterans affairs (VA) system. This study analyzes trends in utilization and 30-day post-operative outcomes between OHR, LHR, and RHR in veterans.Methods This is a retrospective review of patients that underwent inguinal herniorrhaphy using the Veterans Affairs Quality Improvement Program database. Multivariable analysis of outcomes was performed adjusting for pre-operative confounding covariates between OHR, LHR, and RHR. Trends in utilization, complication rates, and operative times were also reported.ResultsFrom 2008–2019, 124,978 cases of inguinal herniorrhaphy were identified: 100,880 (80.7%) OHR, 18,035 (14.4%) LHR, and 6063 (4.9%) RHR. Compared to LHR, RHR was associated with 4.94 times higher odds of complications, 100 min longer mean operative time, and 1.5 days longer median length of stay (LOS). Compared to OHR, RHR was associated with 5.92 times higher odds of complications, 57 min longer mean operative time, and 1.1 days longer median LOS. Utilization of RHR and LHR significantly increased over time. RHR complication rates decreased over time (2008: 20.8% to 2019: 3.2%) along with mean operative times (2008: 4.9 h to 2019: 2.8 h; p < 0.05).Conclusion While this study demonstrated inferior outcomes after RHR, the temporal trends are encouraging. This may be due to increased surgeon experience with robotics. Further prospective data will elucidate the role of RHR as this technique increases.
... 17 Of the remaining 22 observational studies, 6 were conference abstracts. 23,26,28,32,33,37 The robotic approach was compared with the open approach in 14 studies (Table 2), [19][20][21][22][23][24][25][26][28][29][30]32,35,36 while the robotic approach was compared with the laparoscopic approach in 18 studies (Table 1). [18][19][20][21][24][25][26][27][28][31][32][33][34][35][36][37][38][39] The majority of the studies were performed within the US, with 2 performed at non-US institutions. ...
... 17 Of the remaining 22 observational studies, 6 were conference abstracts. 23,26,28,32,33,37 The robotic approach was compared with the open approach in 14 studies (Table 2), [19][20][21][22][23][24][25][26][28][29][30]32,35,36 while the robotic approach was compared with the laparoscopic approach in 18 studies (Table 1). [18][19][20][21][24][25][26][27][28][31][32][33][34][35][36][37][38][39] The majority of the studies were performed within the US, with 2 performed at non-US institutions. ...
... 23,26,28,32,33,37 The robotic approach was compared with the open approach in 14 studies (Table 2), [19][20][21][22][23][24][25][26][28][29][30]32,35,36 while the robotic approach was compared with the laparoscopic approach in 18 studies (Table 1). [18][19][20][21][24][25][26][27][28][31][32][33][34][35][36][37][38][39] The majority of the studies were performed within the US, with 2 performed at non-US institutions. 26,34 Eight studies analyzed patients from prospectively maintained datasets. ...
Article
Over 20 million inguinal hernia repairs are performed worldwide annually.¹ Robot-assisted repair has seen significant growth in the U.S. due to perceived benefits of its magnified three-dimensional visualization and superior range of motion in carrying out fine dissection,² however clinical and cost benefits have yet to be established. In this study, we perform a systematic review of robot-assisted inguinal hernia repair compared with the laparoscopic and open approaches to evaluate intraoperative and short-term outcomes, including pain and hernia recurrence, as well as cost.
... In 14% of the articles, authors declared that they had not received funding [25,33,38,41,52], but 49% did not declare whether they were funded or not [20-24, 26, 27, 29, 31, 32, 39, 40, 44-46, 50, 53]. In the included articles, 46% declared a conflict of interest [3, 28-31, 35-38, 42, 43, 46-49, 51], 46% declared they had no conflict of interest [20, 22-27, 32-34, 40, 41, 44, 45, 52, 53], and 8% did not declare whether or not they had conflicts of interest [21,39,50]. Of the included articles, 37% were affiliated with Intuitive Surgical. ...
... The prevalence of spin can be seen in Table 3. Spin occurred in 57% of the articles [20, 21, 27-30, 32-37, 40, 42, 44, 46, 48-51] and within these, 95% had spin in the abstract [20, 21, 27-30, 32-36, 40, 42, 44, 46, 48-51] and 80% had in the main text conclusion [21,28,29,33,36,40,44,46,[48][49][50][51]. The most common form of spin was claiming non-significance as equivalence (40%), followed by the use of excessive language (29%), excessive focus on statistically significant results (23%), and claimed benefit despite non-significance (23%) ( Table 4). ...
Article
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Background The number of scientific articles published each year is increasing, resulting in greater competition to get work published. Spin is defined as specific reporting strategies used to distort the readers’ interpretation of results so that they are viewed more favorable. However, prevalence of spin in studies comparing robot-assisted groin hernia repair with traditional methods is unknown.Objectives/aimTo determine the frequency and extent of spin in studies assessing robot-assisted groin hernia repair.Methods This systematic review was reported according to PRISMA guidelines, and a protocol was registered at PROSPERO before data extraction. Database search included PubMed, EMBASE, and Cochrane Central.ResultsOf 35 included studies, spin was present in 57%. Within these, 95% had spin present in the abstract and 80% in the conclusion of the article. There was no association between study size and spin (p > 0.05). However, presence of spin in studies positively minded towards robot-assisted hernia repair was higher (p < 0.001) compared with those against or being neutral in their view of the procedure. Furthermore, being funded by or receiving grants from Intuitive Surgical were associated with a higher prevalence of spin (p < 0.05) compared with those who were not.Conclusion Spin was found to be common in articles reporting on robot-assisted groin hernia repair, and presence of spin was higher in studies funded by or receiving grants from the robot company. This suggests that readers should be cautious when reading similar literature.
... However, only a few studies comparing the laparoscopic and the robotic approach have been published [4][5][6][7][8][9][10][11][12][13][14][15][16]. The majority of them were characterized by small sample size, especially in the robotic arm, [6,7,9,16,17], limiting the power and, thus, the generalizability, of the studies. ...
... However, only a few studies comparing the laparoscopic and the robotic approach have been published [4][5][6][7][8][9][10][11][12][13][14][15][16]. The majority of them were characterized by small sample size, especially in the robotic arm, [6,7,9,16,17], limiting the power and, thus, the generalizability, of the studies. ...
Article
Full-text available
The aim of this study was to review the latest evidence on the robotic approach (RHR) for inguinal hernia repair comparing the pooled outcome of this technique with those of the standard laparoscopic procedure (LHR). A systematic literature search was performed in PubMed, Web of Science and Scopus for studies published between 2010 and 2021 concerning the comparison between RHR versus LHR. After screening 582 articles, 9 articles with a total of 64,426 patients (7589 RHRs) were eligible for inclusion. Among preoperative variables, a pooled higher ratio of ASA > 2 patients was found in the robotic group (12.4 vs 8.6%, p < 0.001). Unilateral hernia repair was more common in the laparoscopic group (79.9 vs 68.1, p < 0.001). Overall, operative time was longer in the robotic group (160 vs 90 min, p < 0.001); this was confirmed also in the sub-analysis on unilateral procedures (88 vs 68 min, p = 0.040). The operative time for robotic bilateral repair was similar to the laparoscopic one (111 vs 100, p = 0.797). Conversion to open surgery was 0% in the robotic group. The pooled rate of chronic pain and postoperative complications was similar between the groups. The standardized mean difference MD of the costs between LHR versus RHR was − 3270$ (95% CI – 4757 to − 1782, p < 0.001). In conclusion, laparoscopic and robotic inguinal hernia repair have similar safety parameters and postoperative outcomes. Robotic approach may require longer operative time if the unilateral repair is performed. Costs are higher in the robotic group.
... In this series, we describe the implementation of a new, and ultimately safe robotic program in a major hospital in the Middle East. Importantly, our results are consistent with other investigators, who have shown that robotic surgery can be performed effectively for gallbladder, inguinal hernia, and ventral hernia surgery [9][10][11]. ...
Article
Full-text available
The rapid acceptance of robotic surgery in gallbladder, inguinal, and ventral hernia surgery has led to the growth of robotic surgery programs around the world. As this is new technology, implementation of such programs needs to be done safely, with a focus on patient outcomes. We herein describe the implementation of a new robotic surgery program in a major hospital in the Middle East. A laparoendoscopic surgeon led the program after training and proctoring. Competency based credentialing were created and put in place. To confirm safety of the program, all laparoscopic and robotic cholecystectomy and hernia operations were followed, and perioperative data analyzed. Out of the 304 patients included in this study, 157 were performed using the robotic approach. In the cholecystectomy group ( n = 103) the single site approach offered shorter operative times ( P < 0.05). Both the single site robotic and the robotic assisted approaches resulted in less pain ( P < 0.05). In the inguinal hernia group ( n = 146) the laparoscopic approach offered shorter operative times ( P < 0.05), but the robotic approach was associated with less pain ( P < 0.05). In the ventral hernia group ( n = 55), the open approach offered the best operative times, but the robotic approach was associated with the least amount of pain ( P < 0.05). This is the first report of the implementation of a robotic program in the MENA region where the primary measure of success is outcomes. We show that monitoring cholecystectomy, inguinal or ventral hernia data can confirm the quality of the program before expansion and moving forward to more complex procedures.
... La reparación robótica de la hernia inguinal es la progresión natural de este proceso, utilizando esos mismos principios operativos, pero con avances críticos que cambian tanto la experiencia del paciente como del cirujano. [4][5][6] Para el cirujano, la cirugía robótica permite una vista tridimensional del campo de operación al tiempo que proporciona una muñeca articulada, lo que mejora enormemente la experiencia ergonómica de las tradicionales «pinzas rectas» utilizadas en cirugía laparoscópica. [7][8][9] El objetivo de este trabajo es describir la experiencia de un mismo equipo quirúrgico ejecutando los abordajes transabdominal preperitoneal (TAPP) y Stoppa modificado, ambos asistidos por robot. ...
Article
With more than 5500 da Vinci Surgical System (DVSS) installed worldwide, the robotic approach for general surgery, including for inguinal hernia repair, is gaining popularity in the USA. However, in many countries outside the USA, robotic surgery is performed at only a few advanced institutions; therefore, its advantages over the open or laparoscopic approaches for inguinal hernia repair are unclear. Several retrospective studies have demonstrated the safety and feasibility of robotic inguinal hernia repair, but there is still no firm evidence to support the superiority of robotic surgery for this procedure or its long-term clinical outcomes. Robotic surgery has the potential to overcome the disadvantages of conventional laparoscopic surgery through appropriate utilization of technological advantages, such as wristed instruments, tremor filtering, and high-resolution 3D images. The potential benefits of robotic inguinal hernia repair are lower rates of complications or recurrence than open and laparoscopic surgery, with less postoperative pain, and a rapid learning curve for surgeons. In this review, we summarize the current status and future prospects of robotic inguinal hernia repair and discuss the issues associated with this procedure.
Article
Introduction: Robotic surgery was first introduced in the mid-1980s, and at the end of the '90s, the da Vinci® System (Intuitive Surgical Inc., Sunnyvale, California) was introduced in Europe and held a monopoly for years afterward. In 2016, Senhance™ digital laparoscopic platform (TransEnterix Inc., Morrisville, North Carolina) came to the market. This new platform is based on laparoscopic movements and is designed for laparoscopic surgeons. This study shows the surgical outcomes of patients after different visceral, colorectal, gynecological, and urological surgical procedures done with the Senhance™ digital laparoscopic platform with a focus on safety. Materials and methods: The study population consists of 871 patients who underwent robotic surgery with the Senhance™ platform. The most common procedures were hernia repairs (unilateral and bilateral), cholecystectomies, and prostatectomies. The procedures were performed in five centers in Europe between February 2017 and July 2020 by experienced laparoscopic surgeons. Results: 220 (25.3 %) out of 871 patients had a unilateral hernia repair, 70 (8.0%) a bilateral hernia repair, 159 (18.3%) underwent a cholecystectomy, and 168 (19.3%) a prostatectomy. The other procedures included visceral, colorectal, and gynecological surgery procedures. The median docking time was 7.46 minutes for the four most common procedures. The duration of surgery varied from 32 to 313 minutes, the average time was 114.31 minutes. Adverse events were rare overall. There were 48 (5.5 %) adverse events out of 871 patients, 24 of them (2.8 % of all cases) were severe. Out of all 24 severe adverse events, five events (20.8%) were likely related to the robot, 17 events (70.8%) were unlikely related to the robot, and two events (8.3%) could not be categorized. Regarding complications following unilateral hernia repairs, data from 212 patients was available. Thirteen (6.1%) complications occurred, and six of those (2.8%) were serious. Out of 68 patients with a bilateral hernia repair, six patients (8.8%) developed complications, three of which were severe (4.4%). The complication rate was 2.8% in the patients following a cholecystectomy (4/144); two of them serious. After prostatectomy, six out of 141 patients (4.3 %) had complications; one serious (0.7%) No mortality was observed. Data about unplanned conversions to laparoscopic surgery could be collected from 761 patients which is a rate of 3.7%. There were 12 conversions out of 760 procedures to open surgery (1.6%). Conclusions: Our series shows these procedures are safe and reproducible. The findings suggest that the surgical results after robotic surgery with the Senhance™ system are promising. Long-term data regarding complication rates should be the subject of future studies.
Article
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Purpose The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair. Methods PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed. Results Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50–1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32–1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39–1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37–2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27–1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48–1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63–3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57–1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65–1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63–2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45–2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay. Conclusions This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.
Article
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Purpose As the ultimate procedure which each surgeon decides to perform for a unilateral uncomplicated inguinal hernia remains controversial, we queried the Americas Hernia Society Quality Collaborative (AHSQC) database to report the collective experience of surgeons in the United States whom contribute to AHSQC to provide a view of the surgical approaches performed. Methods The AHSQC data registry was queried for all adult patients who underwent a primary, unilateral, elective, inguinal hernia repair. A retrospective review was conducted to analyze patient demographics, hernia characteristics, operative details, and post-operative outcomes. Our main outcomes of interest were 30-day surgical site infections (SSI), surgical site occurrences (SSO), 30-day patient-reported outcomes, and 1-year recurrence rates. Results 4613 patients met inclusion criteria. 1925 were repaired using an open technique (42%), 1841 were repaired using a laparoscopic technique (40%), and 847 were repaired using a robotic technique (18%). The Shouldice technique remains the most common tissue-based repair performed in the AHSQC. The Lichtenstein repair is the most common open mesh-based repair. Minimally invasive approaches to unilateral inguinal hernia repairs remained very common in our series. The robotic approach accounted for nearly one-third of the minimally invasive inguinal hernia repairs. Conclusion In general, all of the repair techniques reported similar and low rates of 30-day complications. The AHSQC continues on-going efforts to improve long-term follow-up and looks forward to addressing long-term outcomes such as recurrence and chronic pain with increasing data acquisition.
Article
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Despite growing popularity and potential advantages of robotics in general surgery, there is very little published data regarding robotic inguinal hernia repair. This study examines a single surgeon's early experience with robotic TAPP inguinal hernia repair compared with laparoscopic TAPP repair in terms of feasibility and cost. We performed a retrospective review of 63 consecutive patients (24 laparoscopic and 39 robotic) who underwent inguinal hernia repair between December 2012-December 2014 at a single institution by a single surgeon. Data examined included gender, age, BMI, operative times, recovery room times, pain scale ratings, and cost. Patient groups were the same in terms of age and BMI. The mean operative time (77.5 vs 60.7 min, p = 0.001) and room time (109.3 vs 93.0 min, p = 0.001) were significantly longer for the robotic vs the laparoscopic patients. Recovery room time (109.1 vs 133.5 min, p = 0.026) and average pain scores in recovery (2.5 vs 3.8, p = 0.02) were significantly less for the robotic group. The average direct cost of the laparoscopic group was $3216 compared with $3479 for the robotic group. The average contribution margin for the laparoscopic group was $2396 compared with $2489 for the robotic group. Robotic TAPP inguinal hernia repair had longer operative times, but patients spent less time in recovery and noted less pain than patients who underwent laparoscopic TAPP inguinal hernia repair. The direct cost and contribution margin are nearly equivalent. These results should allow the continued investigation of this technique without concern over excess cost.
Article
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Background: One of the proposed advantages of laparoscopic inguinal hernia repair is complimentary inspection of the contralateral side and possible detection of occult hernias. Incidence of occult contralateral hernias is as high as 50 %. The natural course of such occult defects is unknown and therefore operative rationale is lacking. This study was designed to analyze the incidence of occult contralateral inguinal hernias and its natural course. Methods: A total of 1,681 patients were diagnosed preoperatively with unilateral inguinal hernia. None of these patients had complaints of the contralateral side preoperatively. All patients underwent laparoscopic inguinal hernia transabdominal preperitoneal (TAPP) repair. Operative details were analyzed retrospectively. Patients with occult contralateral defects were identified and tracked. Patients with an evident occult hernia received immediate repair. Patients with a smaller beginning or incipient hernia were followed. Results: In 218 (13 %) patients, an occult hernia was found at the contralateral side during preoperative exploration. In 129 (8 %) patients, an occult true hernia was found. In 89 (5 %) patients, an occult incipient hernia was found. An incipient hernia was defined as a beginning hernia. All patients with an incipient hernia were followed. The mean follow-up was 112 (range 16-218) months. Twenty-eight (32 %) patients were lost to follow-up. In the 61 remaining patients, 13 (21 %) occult incipient hernias became symptomatic requiring repair. The mean time between primary repair and development of a symptomatic hernia on the contralateral side was 88 (range 24-210) months. Conclusions: This study shows that the incidence of occult contralateral hernias is 13 % during TAPP repair of unilateral diagnosed inguinal hernias. In 5 % of the cases, the occult hernia consisted of a beginning hernia. Eventually, one of five will become symptomatic and require repair. These outcomes support immediate repair of occult defects, no matter its size.
Article
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IntroductionGuidelines are the bridge between science and clinical practice [1]. Science is a dynamic process and it is continuously evolving. Consequently, there is a continual development of new insights necessitation updates of existing guidelines. For this update, the authors concentrated on studies with level of 1 and 2 evidence. All references are marked with the level of evidence, according to the Oxford classification. In general “Recommendation Grade D” does not constitute a recommendation, but in some instances it is shown in the text to indicate lack of quality data. We recommended all readers to download the original statements and recommendations [2], for fully appreciation of the Update Guidelines on Laparoscopic Hernia Surgery.Updates should include issues that were not yet sufficiently covered in the original guidelines or those which have gained increased clinical importance. For this reason, the Update includes four new chapters: single port surgery, convalescence, co ...
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The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.
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Background Inguinal hernia repair is a common low‐risk intervention. Patient‐reported outcomes (PROs) are being used increasingly as primary outcomes in clinical trials. The aim of this study was to review and meta‐analyse the PROs in RCTs comparing laparoscopic versus open inguinal hernia repair techniques in adult patients. Methods A systematic review and meta‐analysis was carried out in accordance with PRISMA guidelines. Only RCTs in peer‐reviewed journals were considered. PubMed, Ovid Embase, Scopus and the Cochrane Library were searched. In addition, four trial registries were searched. The search interval was between 1 January 1998 and 1 May 2018. Identified publications were reviewed independently by two authors. The review was registered in the PROSPERO database (CRD42018099552). Bias was assessed using the Cochrane Collaboration risk‐of‐bias tool. Results Some 7192 records were identified, from which 58 unique RCTs were selected. Laparoscopic hernia repair was associated with significantly less postoperative pain in three intervals: from 2 weeks to within 6 months after surgery (risk ratio (RR) 0·74, 95 per cent c.i. 0·62 to 0·88), 6 months to 1 year (RR 0·74, 0·59 to 0·93) and 1 year onwards (RR 0·62, 0·47 to 0·82). Paraesthesia (RR 0·27, 0·18 to 0·40) and patient‐reported satisfaction (RR 0·91, 0·85 to 0·98) were also significantly better in the laparoscopic repair group. Conclusion The data and analysis reported in this study reflect the most up‐to‐date evidence available for the surgeon to counsel patients. It was constrained by heterogeneity of reporting for several outcomes.
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Background: Recent NICE guidelines recommend open surgical approaches for the treatment of primary unilateral inguinal hernias. However, many surgeons perform a laparoscopic approach based on the advantages of less post-operative pain and faster recovery. Our aim was to examine current evidence comparing transabdominal pre-peritoneal (TAPP) laparoscopic repair and open surgical repair for primary inguinal hernias. Methods: A systematic search of six electronic databases was conducted for randomised controlled trials (RCTs) comparing TAPP and open repair for primary unilateral inguinal hernia. A random-effects model was used to combine the data. Results: A total of 13 RCTs were identified, with 1310 patients receiving TAPP repair and 1331 patients receiving open repair. There was no significant difference between the two groups for rates of haematoma (RR 0.92; 95% CI 0.49-1.71; P = 0.78), seroma (RR 1.90; 95% CI 0.87-4.14; P = 0.10), urinary retention (RR 0.99; 95% CI 0.36-2.76; P = 0.99), infection (RR 0.61; 95% CI 0.29-1.28; P = 0.19), and hernia recurrence (RR 0.67; 95% CI 0.42-1.07; P = 0.10). TAPP repair had a significantly lower rate of paraesthesia (RR 0.20; 95% CI 0.08-0.50; P = 0.0005), shorter bed stay (2.4 ± 1.4 vs 3.1 ± 1.6 days, P = 0.0006), and shorter return to normal activities (9.5 ± 7.9 vs 17.3 ± 8.4 days, P < 0.00001). Conclusions: Our findings demonstrated that TAPP repair did not have higher rate of morbidity or hernia recurrence and is an equivalent approach to open repair, with the advantages of faster recovery and reduced paraesthesia.
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Inguinal hernias have been described throughout the history of medicine with many efforts to achieve the cure. Currently, with the advantages of minimally invasive surgery, new questions arise: what is going to be the best approach for inguinal hernia repair? Is there a real benefit with the robotic approach? Should minimally invasive hernia surgery be the standard of care? In this report we address these questions by describing our experience with robotic inguinal hernia repair. J. Surg. Oncol. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.
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Hernia (Greek kele/hernios--bud or offshoot) was present in the human history from its very beginning. The role of surgery was restricted to the treatment of huge umbilical and groin hernias and life-threatening incarcerated hernias. The treatment of groin hernia can be divided into five eras. The oldest epoch was ancient era from ancient Egypt to 15th century. The Egyptian Papirus of Ebers contains description of a hernia: swelling that comes out during coughing. Most essential knowledge concerning hernias in ancient times derives from Galen. This knowledge with minor modifications was valid during Middle Ages and eventually in the Renaissance the second era of hernia treatment began. Herniology flourished mainly due to many anatomical discoveries. In spite of many important discoveries from 18th to 19th century the treatment results were still unsatisfactory. Astley Coooper stated that no disease treated surgically involves from surgeon so broad knowledge and skills as hernia and its many variants. Introduction of anesthesia and antiseptic procedures constituted the beginning of modern hernia surgery known as era of hernia repair under tension (19th to middle 20th century). Three substantial rules were introduced to hernia repair technique: antiseptic and aseptic procedures. high ligation of hernia sac and narrowing of the internal inguinal ring. In spite of the progress the treatment results were poor. Recurrence rate during four years was ca. 100% and postoperative mortality gained even 7%. The treatment results were satisfactory after new surgical technique described by Bassini was implemented. Bassini introduced the next rule of hernia repair ie. reconstruction of the posterior wall of inguinal canal. The next landmark in inguinal hernia surgery was the method described by Canadian surgeon E. Shouldice. He proposed imbrication of the transverse fascia and strengthening of the posterior wall of inguinal canal by four layers of fasciae and aponeuroses of oblique muscles. These modifications decreased recurrence rate to 3%. The next epoch in the history of hernia surgery lasting to present days is referred to as era of tensionless hernia repair. The tension of sutured layers was reduced by incisions of the rectal abdominal muscle sheath or using of foreign materials. The turning point in hernia surgery was discovery of synthetic polymers by Carothers in 1935. The first tensionless technique described by Lichtenstein was based on strengthening of the posterior wall of inguinal canal with prosthetic material. Lichtenstein published the data on 1,000 operations with Marlex mesh without any recurrence in 5 years after surgery. Thus fifth rule of groin hernia repair was introduces--tensionless repair. Another treatment method was popularized by Rene Stoppa, who used Dacron mesh situated in preperitoneal space without fixing sutures. Fist such operation was performed in 1975, and reported recurrence rates were quite low (1.4%). The next type of repair procedure was sticking of a synthetic plug into inguinal canal. Lichtenstein in 1968 used Marlex mesh plug (in shape of a cigarette) in the treatment of inguinal and femoral hernias. The mesh was fixated with single sutures. The next step was introduction of a Prolene Hernia System which enabled repair of the tissue defect in three spaces: preperitoneal, above transverse fascia and inside inguinal canal. Laproscopic treatment of groin hernias began in 20th century. The first laparoscopic procedure was performed by P. Fletcher in 1979. In 1990 Schultz plugged inguinal canal with polypropylene mesh. Later such methods like TAPP and TEP were introduced. The disadvantages of laparoscopic approach were: high cost and risk connected with general anesthesia. In conclusion it may be stated that history of groin hernia repair evolved from life-saving procedures in case of incarcerated hernias to elective operations performed within the limits of 1 day surgery.