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AbstractObjectiveTo determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair.DesignPragmatic, blinded randomized controlled trial.SettingMultidisciplinary hernia clinics in Houston, USA.Participants124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019.InterventionsRobotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59).Main outcome measuresThe primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat.ResultsPatients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair.ConclusionThis study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs.Trial registrationClinicaltrials.gov NCT03490266.

There is variation in the anesthetic technique for open inguinal hernia repair (OIHR) worldwide. Factors determining the anesthetic technique remains equivocal. We hypothesize that outcomes and operative room times are superior with local anesthesia (LA) compared to AO [all others (general and spinal anesthesia)]. Following PRISMA guidelines and set inclusion and exclusion criteria, various databases were reviewed and 18 RCT's were isolated. Using ReviewManager 5.3, multiple parameters were used to test for overall effect between the included studies. Overall complication rate was similar in LA vs. AO (p = 0.06). Wound infection and hematomas were similar between LA vs. OA, but urinary retention was significantly decreased in LA (p = 0.0002). Patient satisfaction was not inferior with LA (p = 0.10). Surgical time was similar in LA vs. AO (p = 0.86), but operating room time was significantly decreased with LA (p < 0.0001). The literature review also showed a decrease in the LOS and cost when LA was used. This meta-analysis demonstrates that LA is a well-tolerated for OIHR with OR times and urinary retention being significantly decreased. •Local anesthesia is a well-tolerated anesthetic technique for open inguinal hernia repairs.•Total operating room times and urinary retention are significantly improved when local anesthesia is utilized.•Local anesthesia is a cost effective anesthetic technique for open inguinal hernia repair.

Background Enhanced View Totally Extraperitoneal (eTEP) and Intraperitoneal Onlay Mesh (IPOM) are two widely performed laparoscopic approaches for ventral hernia repair. This randomized prospective study aimed to compare these two techniques in terms of various clinical outcomes. Materials and methods A total of 60 patients presenting with ventral hernias at our hospital between June 2022 and December 2023 were included in the study. All patients were fit for general anesthesia and were randomized into two groups, with 30 patients undergoing eTEP and 30 patients undergoing IPOM. Results There were no significant differences in baseline characteristics such as age, sex, or comorbidities between the two groups. The operative time for eTEP was significantly longer, with a mean duration of 211 min compared to 177.5 min for IPOM ( p  < 0.001). Postoperative pain and analgesic requirements were significantly lower in the eTEP group. Two patients in the eTEP group required conversion to IPOM. No intraoperative complications occurred in either group. Two patients developed seromas on the seventh postoperative day, both of which were managed conservatively. The mean hospital stay was shorter for eTEP (3.43 days) compared to IPOM (6.16 days, p  < 0.001). Patients undergoing eTEP had an earlier return to work and reported better abdominal wall quality of life. No recurrences were observed in either group during the six-month follow-up period. Conclusion eTEP repair for ventral hernias offers several advantages over the commonly performed IPOM technique, including reduced postoperative pain, shorter hospital stay, and faster recovery. However, the choice of procedure should be guided by the surgeon’s expertise and confidence in performing either technique.

Introduction The use of biological graft in laparoscopic inguinal hernia repair (LIHR) has been controversial, and there is a lack of high-level evidence to confirm the value of biological graft in LIHR. The purpose of this study is to evaluate the effectiveness of a novel composite biologics in LIHR. Methods A multicenter, single-blinded, randomized controlled clinical trial was designed. Fifty patients with unilateral primary inguinal hernia were randomly assigned to the experimental and control group (1:1). The experimental group was repaired with a non-crosslinked composite extracellular matrix from porcine urinary bladder matrix and small intestinal submucosa (UBM/SIS). The control group was repaired with a lightweight, large-pore, synthetic mesh. The primary endpoint was the effectiveness rate of hernia repair. Results The patients were followed up for four years. No significant difference was found between the experimental group and the control group in the effective rate of hernia repair (24/24[100%] vs 21/22[95.45%], RR, 0.4667; 95%CI, 0.3294–2.304; P  = 0.4783). There was no fever, seroma, infection, groin pain, foreign body discomfort or recurrence in the experimental group during the follow-up. In the control group, there were 2 cases of seroma 14 days after operation, 1 case of groin discomfort 60 days after operation and one case of recurrence 410 days after surgery. Conclusion Compared with the lightweight synthetic mesh, the novel UBM/SIS graft has comparable short-term and medium-term effectiveness in LIHR, and the incidence of postoperative complications such as seroma groin discomfort is lower. Trial registration Clinical Trials Registry: ChiCTR1800020173.

Purpose In laparoscopic inguinal hernia repair, it is thought that the mesh can be displaced more in the enhanced-view totally extraperitoneal (eTEP) technique. The aim of this study was to compare eTEP and totally extraperitoneal (TEP) techniques without mesh fixation in terms of mesh displacement and hernia recurrence. Methods Between December 2022 and April 2023, 60 consecutive patients with unilateral inguinal hernia were randomized into two groups; eTEP group ( n  = 30) and TEP group ( n  = 30). There was without mesh fixation in both groups. Study was registered at http://Clinicaltrials.gov (NCT06070142). The mesh was marked with three radiopaque clips. Pelvic radiographs were performed to evaluate the displacement of the mesh. The primary outcome of this study was mesh displacement. In addition, this is the first study in the literature to compare eTEP and TEP techniques in terms of mesh displacement without fixation in laparoscopic inguinal hernia. Results There was no significant difference between the groups in terms of mesh displacement, recurrence, postoperative VAS scores, length of hospital stay, hematoma, and seroma formation. The operation time was higher in the eTEP group and was statistically significant. Conclusion Without mesh fixation, the eTEP technique does not increase the risk of mesh displacement and recurrence. The eTEP technique can be safely applied without mesh fixation in laparoscopic inguinal hernia repairs. Trial registration ClinicalTrials number: NCT06070142.

This is the first randomised controlled trial to assess the operating ergonomics of open console robotic surgery for inguinal hernia surgery. Intraoperative ergonomic risk was assessed using the Rapid Entire Body Assessment (REBA) scale, with photographs taken at 1-min intervals. Secondary outcomes included team nontechnical skills (NTS) assessment, surgeon cognitive strain, and patient clinical outcomes. Patients were stratified on unilateral/bilateral hernias. Sixty patients were randomised, 1 was withdrawn (39 robot:20 lap). Robotic REBA scores were significantly lower than laparoscopic (median robot 3.0 vs lap 5.0 [p ​< ​0.001]). Robotic operations were longer (mean 64.9 ​± ​21.1 ​min vs 31.7 ​± ​10.3 ​min [p ​< ​0.001]). More robotic patients had resumed normal activities at 14-days (15(39 ​%) vs 1(5 ​%) [p ​= ​0.006]). Team NTS (Oxford NOTECHS II) and surgeon cognitive strain (modified NASA-TLX) were unaffected by modality, and all other patient outcomes were equal. This trial demonstrates that robotic surgery reduces ergonomic risk during inguinal hernia surgery, with no detriment to cognitive strain or team functioning. This may therefore be a safe & feasible solution to the increasing problem of work-related musculoskeletal injuries in surgeons. •Laparoscopic surgery is ergonomically risky and leads to injuries & pain amongst surgeons.•This trial compares the ergonomics of laparoscopic & open console robotic inguinal hernia surgery.•Robotic assistance significantly lowered surgeon ergonomic risk from medium to low.•Team nontechnical skills, cognitive strain, and patient outcomes were unaffected by modality.

Introduction Older adult patients have many factors to contemplate when considering elective ventral hernia repair. In this study, we aimed to understand whether our novel shared decision-making (SDM) aid helped reduce this population’s decisional regret when choosing hernia management strategy. Methods Patients ≥ 60 years of age presenting for ventral hernia evaluation were randomized to two groups. The experimental group had their visit guided by our novel SDM aid. All patients took a survey prior to consultation outlining their treatment expectations. All patients were called within 6 months to complete the Decision Regret Scale, which measures remorse after a healthcare decision. Results Seventy-two patients (36 control, 36 experimental) completed final follow-up. On initial expectations evaluation, 53 patients (74%) reported wanting surgical repair and 58 patients (81%) reported expecting surgical repair. Ultimately, 18 patients in the control group and 17 patients in the experimental group did not undergo surgery. The use of the SDM aid did not affect if patients chose observation (OR 0.44, p  = 0.24) or result in a lower decision regret score (9.86 vs 9.31, p  = 0.89). Surgery was associated with a lower decision regret score (3.38 vs 16.14; p  = 0.001). Of those who did not undergo repair, patients initially wanting or expecting surgery had higher decision regret scores (22.83 vs 3.33, p  < 0.001; 20.40 vs 5.50, p  = 0.009). Nonoperative patients who chose observation had less regret than those needing medical optimization (9.50 vs 25.00, p  = 0.04). There were no differences in decision regret scores based on initial wants or expectations for those who had surgical repair. Conclusion Decisional regret following ventral hernia management is associated with patients’ expectations prior to initial surgical consultation. The use of a decisional aid did not lower decision regret scores. These findings emphasize the need for upfront expectation setting and longitudinal programs to help patients reach their treatment goals. Graphical abstract

IntroductionFixation of mesh during minimally invasive inguinal hernia repair is thought to contribute to chronic post-herniorrhaphy groin pain (CGP). In contrast to permanent tacks, absorbable tacks are hypothesized to minimize the likelihood of CGP. This study aimed to compare the rates of CGP after laparoscopic inguinal hernia repair between absorbable versus permanent fixation at maximum follow-up.MethodsThis is a post hoc analysis of a randomized controlled trial in patients undergoing laparoscopic inguinal hernia repair (NCT03835351). All patients were contacted at maximum follow-up after surgery to administer EuraHS quality of life (QoL) surveys. The pain and restriction of activity subdomains of the survey were utilized. The primary outcome was rate of CGP, as defined by a EuraHS QoL pain domain score ≥ 4 measured at ≥ 1 year postoperatively. The secondary outcomes were pain and restriction of activity domain scores and hernia recurrence at maximum follow-up.ResultsA total of 338 patients were contacted at a mean follow-up of 28 ± 11 months. 181 patients received permanent tacks and 157 patients received absorbable tacks during their repair. At maximum follow-up, the rates of CGP (27 [15%] vs 28 [18%], P = 0.47), average pain scores (1.78 ± 4.38 vs 2.32 ± 5.40, P = 0.22), restriction of activity scores (1.39 ± 4.32 vs 2.48 ± 7.45, P = 0.18), and the number of patients who reported an inguinal bulge (18 [9.9%] vs 15 [9.5%], P = 0.9) were similar between patients with permanent versus absorbable tacks. On multivariable analysis, there was no significant difference in the odds of CGP between the two groups (OR 1.23, 95% CI [0.60, 2.50]).ConclusionMesh fixation with permanent tacks does not appear to increase the risk of CGP after laparoscopic inguinal hernia repair when compared to fixation with absorbable tacks. Prospective trials are needed to further evaluate this relationship.

BackgroundFor small to medium-sized ventral hernias, robotic intraperitoneal onlay mesh (rIPOM) and enhanced-view totally extraperitoneal (eTEP) repair have emerged as acceptable approaches that each takes advantage of robotic instrumentation. We hypothesized that avoiding mesh fixation in a robotic eTEP repair offers an advantage in early postoperative pain compared to rIPOM.MethodsThis is a multi-center, randomized clinical trial for patients with midline ventral hernias ≤ 7 cm, who were randomized to rIPOM or robotic eTEP. The primary outcome was pain (0–10) on the first postoperative day. Secondary outcomes included same-day discharge, length of stay, opioid consumption, quality of life, surgeon workload, and cost.ResultsBetween November 2019 and November 2021, 100 patients were randomized (49 rIPOM, 51 eTEP) among 5 surgeons. Pain on the first postoperative day [median (IQR): 5 (4–6) vs. 5 (3.5–7), p = 0.66] was similar for rIPOM and eTEP, respectively, a difference maintained following adjustments for surgeon, operative time, baseline pain, and patient co-morbidities (difference 0.28, 95% CI − 0.63 to 1.19, p = 0.56). No differences in pain on the day of surgery, 7, and 30 days after surgery were identified. Same-day discharge, length of stay, opioid consumption, and 30-day quality of life were also comparable, though rIPOM required less surgeon workload (p < 0.001), shorter operative time [107 (86–139) vs. 165 (129–212) min, p < 0.001], and resulted in fewer surgical site occurrences (0 vs. 8, p = 0.004). The total direct costs for rIPOM and eTEP were comparable [$8282 (6979–11835) vs. $8680 (7550–10282), p = 0.52] as the cost savings for eTEP attributable to mesh use [$442 (434–485) vs. $69 (62–76), p =  < 0.0001] were offset by increased expenses for operative time [$669 (579–861) vs. $1075 (787–1367), p < 0.0001] and use of more robotic equipment [$760 (615–933) vs. $946 (798–1203), p = 0.001].ConclusionThe avoidance of fixation in a robotic eTEP repair did not reveal a benefit in postoperative pain to offset the shorter operative time and surgeon workload offered by rIPOM.

Background Open mesh repair of incisional hernia is associated with different local complications, particularly bleeding and seroma formation. Traditionally, drains have been placed perioperatively to prevent these complications, despite the lack of scientific evidence or expert consensus. We formulated the hypothesis that the absence of drainage would reduce number of patients presenting collections or complications. The present study aimed to compare postoperative complication rates after open mesh repair for incisional hernia with or without prophylactic wound drainage. Methods Prospective randomized study using standardized surgical technique and drain placement. The primary endpoint was the evaluation of residual fluid collection with ultrasound on postoperative day 30. Other complications, subdivided into medical and surgical, were analyzed as secondary endpoints. Results There were 144 patients randomized (70 with drain, 74 without drain). No difference was identified between both groups for fluid collection at 30 days (60.3% vs. 62%, p  = 0.844). However, less surgical complications were identified in the drain group (21.7% vs. 42.7%, p  = 0.007), with a lower wound dehiscence rate (1.5% vs. 9.3%, p  = 0.041). Conclusions Prophylactic drainage in open incisional hernia repair does not objectively reduce the rate of postoperative fluid collections. Therefore, our results do not support the use of routine drainage in incisional hernia repair. Trial registration Trial registration on clinicaltrials.gov (NCT00478348).