Inguinal Hernia Repair Research Articles

Management Of Inguinal Hernias In Adults In Mulongo: A Local Anesthesia Approach

Introduction: Inguinal hernia, passage through the transversalis fascia of a peritoneal diverticulum, is a common condition often requiring surgical intervention. It represents one of the most frequent reasons for consultation in surgery, with a worldwide incidence estimated at 4.6% of the population. Objective: Describe the epidemiological, clinical aspects and therapeutic modalities of sublocal hernia repair of inguinal hernias in adults in the territory of Mulongo. Materials and Methods: This descriptive cross-sectional and prospective study was conducted during a campaign of free general surgery operations in Mulongo, Haut-Lomami, DRC, between June 1, 2021 and December 31, 2021. Local anesthesia with xylocaine was used. The parameters evaluated were frequency, age, sex, anatomoclinical type, type of anesthesia and postoperative evolution. Results :A total of 162 patients were included. The mean age was 41.5 years (range: 18-70). There were 90.7% men, the sex ratio was 9.8. The hernia was simple in 95.6% of cases and located on the right in 50% of cases. In 4.4% of cases the hernia was operated on urgently (strangulated and engorged and painful). Postoperative pain was the most common postoperative complication found in 54.9% of cases. Conclusion: The management of inguinal hernias in adults in Mulongo is often carried out under local anesthesia, due to the high prevalence of this pathology in the professional context of patients. Inguinal hernia thus remains a significant problem in this region, justifying adapted approaches such as local anesthesia

Effect of ultrasound-guided lower transverse abdominal muscle plane block on awakening agitation and stress response in laparoscopic inguinal hernia surgery.

Effect of ultrasound-guided lower transverse abdominal muscle plane block on awakening agitation and stress response in laparoscopic inguinal hernia surgery.

The effect of virtual reality hypnosis (HypnoVR) in patients undergoing inguinal hernia repair under local anesthesia. A preliminary report.

Surgical procedures, even under local anesthesia, can induce significant stress and anxiety in patients. Innovative approaches to alleviate anxiety are crucial for improving patient outcomes. Sedatives and anxiolytics may alleviate this discomfort, but they can also subject patients to undesirable side effects, diminishing their overall effectiveness, and, finally, delaying discharge. We present the first case series of a patients underwent inguinal hernia surgical repair under local anesthesia using VRH (HypnoVR) to avoid use of sedatives and anxiolytics. 12 consecutive patients were enrolled to undergo elective monolateral inguinal hernia repair surgery via an open approach using HypnoVR, at Colorectal Surgery Unit of Fondazione Policlinico Universitario Campus Bio-Medico di Roma. Vital signs (heart rate, SpO2, blood pressure) were detected for all patients before surgery, during local anesthesia, during the whole intervention and after surgery. No intraoperative or postoperative complications have been recorded and only one postoperative complication occurred (seroma), which not required invasive treatment but only drug administration. All patient's vital parameters were recorded during all operative and perioperative phasis. No use of intraoperative analgesic, sedative or anxiolytic were needed. All patients were discharged no later than 3h after surgery. Virtual Reality Hypnosis is a promising tool for anxiety management in surgical settings. Our series highlights the positive impact of HypnoVR in reduction and management of surgical patient anxiety and discomfort, allowing to perform inguinal hernia repair using only local anesthesia, with good patients' satisfaction.

Understanding patient experiences to improve care for females groin hernia.

Thousands of females undergo inguinal hernia repair annually, yet females have been excluded from prior clinical trials evaluating inguinal hernia repairs. Research shows females face worse outcomes after hernia repair compared to males, including higher recurrence rates, increased chronic pain, and limited data to guide treatment. Prospective studies focused on optimizing outcomes for females are critically needed. Prior to conducting such trials, it is essential to obtain preliminary data from female participants to ensure that the studies are designed appropriately to address their priorities and improve sex disparities in outcomes. Semi-structured qualitative interviews were conducted between July 7 and December 31, 2023, with 34 females evaluated for groin hernia. Interviews were conducted via Zoom at an academic medical center. The discussions aimed to explore the challenges in diagnosing hernias, the considerations for selecting treatment options, and the priorities for future research. The transcripts were analyzed using descriptive content analysis, facilitated by MAXQDA software. Diagnostic challenges included delayed recognition due to underappreciation of female hernias. Participants desired greater familiarity with hernias and treatment options from providers. For surgical decisions, fear of complications drove some towards surgery, while others prioritized avoiding recovery time for asymptomatic hernias. Participants called for research on female-specific risk factors, pain experiences, recovery impacts, and non-operative approaches. The majority of participants agreed or considered participating and serving as an advisor in a future study. Females with hernia face sex-based disparities in diagnosis and treatment. Improving provider awareness and developing guidelines are needed. This qualitative study identifies key areas for future research to optimize person-centered hernia care for females based directly on personal perspectives and priorities, laying the groundwork for prospective trials aimed at improving outcomes.

Is the transection of the hernia sac during laparoscopic inguinal hernioplasty safe and feasible? An updated systematic review and meta-analysis.

There is a debate over whether to transect or completely reduce the hernia sac during laparoscopic tension-free repair of inguinal hernia. This study endeavors to systematically assess the efficacy and safety of two approaches, namely transected sac (TS) and completely reduced sac (RS), in laparoscopic tension-free repair of inguinal hernia. Utilizing a meta-analysis methodology, we aim to provide a comprehensive analysis of these techniques. A comprehensive search was conducted across PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases to identify comparative studies focusing on laparoscopic tension-free repair of inguinal hernia, specifically comparing TS and RS techniques. The selected studies were subjected to meta-analysis using RevMan 5.3 software. A total of 8 studies, involving 2995 patients with inguinal hernia, were included in the analysis. The meta-analysis results revealed that the TS group had a higher incidence of seroma compared to the RS group [OR = 1.74, 95% CI (1.35, 2.25), P < 0.0001], and a prolonged time to return to normal activity postoperatively [MD = 0.99, 95% CI (0.85, 1.14), P < 0.00001]. However, no statistically significant differences were observed between the two groups in terms of operation time [MD = -1.75, 95% CI (- 8.72, 5.22), P = 0.62], incidence of postoperative pain [OR = 1.00, 95% CI (0.41, 2.44), P = 1.00], overall postoperative complication rate [OR = 0.98, 95% CI (0.43, 2.20), P = 0.95], and recurrence rate fOR = 2.53, 95% CI (0.61, 10.39), P = 0.20]. Transected sac in laparoscopic inguinal hernia repair is associated with an increased incidence of seroma and a longer recovery time for patients to return to normal activity. Clinical trial registration Registration number is INPLASY20223110070.

Navigating hernia sac management in minimally invasive inguinal hernia repair: to abandon or to reduce? An updated systematic review and meta-analysis.

Minimally invasive inguinal hernia repair has become increasingly accepted, demonstrating superior outcomes over open procedures in postoperative complications. However, certain postoperative complications, such as seroma, remain a dilemma, with many attributing it to the management of the hernia sac. We aimed to perform a systematic review and meta-analysis comparing the reduction versus abandonment of the hernia sac during laparoscopic inguinal hernia repair. Cochrane, Scopus, SciELO, and PubMed were searched for studies comparing reduction and abandonment of the hernia sac. Our primary outcome was seroma. Secondary outcomes were overall complications, postoperative pain, surgical site infection, recurrence, hospital length of stay (LOS), and operative time. We performed a subgroup analysis of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. Statistical analysis was performed with R Studio. 2388 studies were screened, and seven studies were included, comprising 3153 patients, of which 916 (29%) were in the abandonment group. We found higher seroma rates for the abandonment group (RR 1.52; 95% CI 1.22 to 1.89; P < 0.001). No differences were found in overall complications (RR 0.88; 95% CI 0.55 to 1.42; P = 0.61), postoperative pain (RR 1.15; 95% CI 0.46 to 2.87; P = 0.76), recurrence (RR 2.67; 95% CI 0.51 to 14.05; P = 0.25), operative time (MD -4.45 min; 95% CI -12.77 to 3.86; P = 0.29), and LOS (MD -0.06 days; 95% CI -0.14 to 0.02; P = 0.14) between both groups. Subgroup analysis of seroma showed no differences between the groups when analyzing TAPP (19.3% vs. 13%; RR 1.65; 95% CI 0.91 to 2.99; P = 0.1) and TEP (9% vs. 4.3%; RR 1.69; 95% CI 0.62 to 4.6; P = 0.3) procedures. Our systematic review and meta-analysis support that hernia sac abandonment may be associated with increased early seroma rates following laparoscopic inguinal hernia repair, but limited data are available for technique-specific analyses.

Inguinal Hernia Repair: Comparative Study between TEP versus Extended Totally Extraperitoneal.

Inguinal hernia repair is a common surgical procedure, with laparoscopic techniques offering advantages over open surgery. The extended Totally Extraperitoneal (eTEP) technique provides a larger working space compared to the traditional Totally Extraperitoneal (TEP) approach, potentially improving outcomes. A prospective study was conducted comparing eTEP and TEP techniques for inguinal hernia repair at Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. Forty patients (20 in each group) aged 15-65 with uncomplicated inguinal hernias were included. Surgical procedures were performed based on patient preference. Data on surgical duration, pain scores, hospital stay, and complications were collected and analyzed using statistical methods. eTEP surgery had a significantly shorter mean duration (48.70 ± 7.505 minutes) compared to TEP surgery (74.20 ± 7.78 minutes; P = 0.00). Patients undergoing eTEP experienced lower mean pain scores (3.75 ± 0.55) compared to those undergoing TEP (5.15 ± 0.745; P = 0.00). Hospital stay following eTEP surgery was shorter (1.70 ± 0.657 days) than following TEP surgery (3.65 ± 1.137 days; P = 0.00). eTEP had lower incidences of hematoma and surgical emphysema but higher seroma complications. TEP surgeries were associated with more post-operative complications and a higher likelihood of requiring conversion to open surgery. The eTEP technique offers several advantages over TEP, including shorter surgical duration, less post-operative pain, and shorter hospital stays. However, TEP had more complications related to seroma. Individual patient factors and surgeon experience should guide the choice of technique. The eTEP technique appears to be a promising option for inguinal hernia repair, offering advantages over TEP in terms of surgical outcomes. However, further studies are needed to evaluate long-term outcomes and complication rates comprehensively.

A Comparative Study of Tackers Versus Sutures in Transabdominal Preperitoneal Hernia Repair: Tackers Versus Sutures in Mesh Fixation and Peritoneal Closure in Tapp

Background: This study evaluates the surgical outcomes of using tackers versus sutures for mesh fixation and peritoneal closure in transabdominal preperitoneal (TAPP) mesh repair of inguinal hernia, focusing on postoperative pain, quality of life, and other key metrics. Although there are many studies in studying various outcomes of Transabdominal preperitoneal mesh repair (TAPP), there exists only few trials that compare peritoneal closure techniques in TAPP Methods: A prospective comparative study was conducted at Mahatma Gandhi Medical College and Research Institute. Sixty patients undergoing TAPP were divided into two groups: one using non-absorbable sutures and the other using non-absorbable titanium tackers for mesh fixation and peritoneal closure. Intraoperative and postoperative outcomes were assessed, including time taken for procedures, postoperative pain (measured using the Visual Analog Scale), incidence of seroma formation, and short-term quality of life assessed using the Carolinas Comfort Scale. Results: The suture group demonstrated significantly less postoperative pain on postoperative day (POD) 1 and at 3 months compared to the tacker group (p=0.001 and p=0.004, respectively). The time taken for mesh fixation and peritoneal closure was shorter in the tacker group, but the overall operative time was significantly longer in the suture group (p=0.001). The cost of using sutures was substantially lower than tackers. Quality of life scores at 3 months indicated better outcomes in the suture group (p=0.001). Conclusions: Sutures for mesh fixation and peritoneal closure in TAPP repair provide better postoperative outcomes in terms of pain, quality of life, and cost compared to tackers, despite a longer operative time. These findings suggest that sutures may be a preferable option for TAPP inguinal hernia repair.

Pneumaturia and Colonic Bleeding Post-Inguinal Herniorrhaphy: A Case Report

Introduction: A 51-year-old male was seen complaining of pneumaturia and bowel complaints, including blood per rectum. The patient related a history of an open left inguinal hernia repair utilizing a Kugel mesh ten years before. Case Presentation: Cystoscopy and colonoscopy demonstrated a hemorrhagic mass due to a prosthetic mesh protruding into the bladder and colon. Following colonoscopy and cystoscopy, a large inflammatory mass involving both the colon and urinary bladder was resected, which contained a rolled-up “tubular” mesh structure. After primary repair of the urinary bladder and placement of a Foley catheter, the sigmoid colon and mesh were resected, and the colonic anastomosis was completed. Outcome: Postoperatively, the patient progressed well with normal colon and bladder function after the removal of the Foley catheter. Discussion: Historically, the patient demonstrated the risk of major multiorgan surgical complications of a newer inguinal hernia repair technique, which may occur even a decade or more after the initial surgical correction and is, therefore, presented.

Surgical training trends in the Americas: A cross-continental assessment of minimally invasive surgery and open surgery among surgical trainees.

Minimally invasive surgery (MIS) has become standard of care in many high-income countries, but its adoption in low- and middle-income countries (LICs/MICs) has been impeded by resource- and training-related barriers. We hypothesized that trainees in MICs perform MIS procedures less often, and that as procedure complexity increases, the rate of MIS decreases. A 22-question survey, distributed to representative leaders across Latin America, collected country-specific graduating trainee case requirements and volumes for four index procedures (cholecystectomy, appendectomy, inguinal hernia repair, colectomy) using MIS or open surgery (OS). USA data was obtained from the Accreditation Council for Graduate Medical Education. Kruskal-Wallis and Mann-Whitney U tests were performed to determine whether the rate of MIS differed across all countries, procedure complexity classes, and high income countries (HICs)/MICs. Seven experts (70% response rate) completed the survey, representing: Brazil, Chile, Ecuador, Guatemala, Mexico, Panama, and Paraguay. The percentage of MIS completed by trainees varied with mean and interquartile ranges as follows: cholecystectomy (60%±54%), appendectomy (41%±69%), inguinal hernia repair (19%±23%), colectomy (16%±29%). There was a significant difference in mean MIS experience across the eight countries (H=17.6, p=0.014) and between most complex and least complex procedures (p=0.039). No difference was found between MICs and HICs (p=0.786). We found a significant difference of general surgery trainee exposure to MIS versus OS across the Americas, but the difference was not significantly associated with World Bank Income Groups. Different trainee experiences with MIS and OS may highlight an opportunity for international and bidirectional collaboration.

Sensory assessment of intramuscular quadratus lumborum block at the L2 level in open inguinal hernia repair patients

BackgroundThe effectiveness of the quadratus lumborum block (QLB) for postoperative pain management depends on the injection pathway used. There is limited research on the block area produced by intramuscular injection of local anesthesia in the quadratus lumborum muscle. This study aimed to determine the cutaneous sensory blockade area produced by an intramuscular quadratus lumborum block (QLBi) at the L2 level.MethodsTwenty patients aged 18–60 years with ASA grade I-II and a BMI of 18–30 kg/m2 who were scheduled for open inguinal hernia repair with mesh underwent ultrasound-guided QLBi injection of 20 ml of 0.5% ropivacaine. The cutaneous sensory blockade area was measured by applying a cold stimulus 1 h after the block and then measured every hour after surgery until the sensation returned to normal. The duration of a blockade is defined as the time it takes for all affected areas to fully regain normal sensation following a blockade. Pain scores (numeric rating scale, NRS) were recorded at 2, 4, 8, 12, and 24 h after surgery. Adverse reactions to QLBi were recorded 24 h after surgery.ResultsAll 20 patients had reduced or lost cold sensation areas. The greatest extent of cold sensation reduction occurred at T7 (10%), and the least amount of cold sensation reduction occurred at L3 (10%). The block level covered T8 (20%), T9 (30%), T10 (45%), T11 (90%), T12 (95%), L1 (100%), and L2 (15%). Eighteen patients experienced areas of sensory loss, with the highest range at T11 and the lowest at L2. The duration of the blockade was 8.9 ± 3.8 h, with a maximum of 24 h and a minimum of 5 h. One patient experienced quadriceps weakness after surgery.ConclusionQuadratus lumborum block of intramuscular pathway can produce effective cutaneous sensory blockade, which can be used for postoperative analgesia of indirect inguinal hernia operation, and may also be beneficial to analgesia of other lower abdominal operations. However, the best method needs further confirmation to determine specific anesthesia methods for various operations.Chinese clinical trial registryJune 2, 2018; ChiCTR1800016457.

Single-port versus multi-port laparoscopic and robotic inguinal hernia repair: a systematic review and network meta-analysis.

The evolution of minimally invasive surgery has transformed inguinal hernia repair (IHR). The innovative single-port technique reduces the number of surgical incisions. However, the benefits of single-port IHR remain controversial. Our systematic review and network meta-analysis assess the efficacy and clinical outcomes of single-port laparoscopic inguinal hernia repair (SPL-IHR), multi-port laparoscopic inguinal hernia repair (MPL-IHR), single-port robotic inguinal hernia repair (SPR-IHR), and multi-port robotic inguinal hernia repair (MPR-IHR). A comprehensive search was conducted in PubMed, EMBASE, Cochrane, and Ovid for articles published before January 2024, focusing on complication rates, recurrence, seroma, hematoma, operative time, post-operative pain, and cosmetic outcomes of laparoscopic or robotic IHR. Both extraperitoneal (TEP) and transabdominal (TAPP) approaches were analyzed using MetaInsight. MPL-TAPP was used as the standard for comparison. Thirty-seven studies, including 5,038 patients, 36.92% (1,860 patients) underwent MPL-TEP, 23.64% (1,191 patients) SPL-TEP, 22.23% (1,120 patients) MPR-TAPP, 10.08% (508 patients) MPL-TAPP, 5.40% (272 patients) SPL-TAPP, and 1.73% (87 patients) SPR-TAPP. There were no significant differences in the rates of post-operative complications, hernia recurrence, hematoma, or seroma among the techniques when compared to MPL-TAPP. For secondary outcomes, MPR-TAPP significantly increased the operative time for unilateral hernia repair by a mean difference (MD) of 10.60 min [95% CI: 2.16-19.04]. Conversely, for bilateral hernia repair, there was no significant difference. Post-operative pain was significantly higher for MPL-TEP and SPL-TEP, with MDs of 1.44 [95% CI: 0.43 to 2.44] and 1.22 [95% CI: 0.18 to 2.26], respectively. SPL-TEP was significantly favored in cosmetic outcomes over MPL-TEP, with an MD of 0.65 [95% CI: 0.07 to 1.24]. In our network meta-analysis, the risk of post-operative complications, including recurrence, hematoma, and seroma, does not significantly vary among single-port and multi-port laparoscopic or robotic techniques. This suggests that surgical technique selection can rely on surgeon expertise and resource availability, without compromising outcomes.

Meta-analysis of RCTs on the safety of non-fixation of mesh in TAPP inguinal hernia repair: an updated meta-analysis

ObjectiveThis meta-analysis aims to compare the clinical efficacy of mesh non-fixation and fixation in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, systematically evaluating the application value of the mesh non-fixation technique in clinical settings.MethodsA computerized search of PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases was conducted to identify randomized controlled trials (RCTs) comparing mesh non-fixation and fixation in TAPP inguinal hernia repair. Meta-analysis was performed using RevMan 5.3 software, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence grading system was employed for outcome quality assessment. Publication bias analysis was performed using Begg’s test. A trial sequential analysis (TSA) was performed using TSA 0.9.5.10 Beta software.ResultsA total of nine RCTs involving 1,879 inguinal hernia patients were included. Meta-analysis results demonstrated that, compared to the fixation group, the non-fixation group exhibited significantly lower seroma occurrence rate [RR = 0.43, 95% CI (0.20, 0.89), P = 0.02, heterogeneity P = 0.28, I²=22%], Visual Analog Scale (VAS) pain score at 6 months postoperatively [MD=-0.21, 95% CI (-0.29, -0.12), P < 0.00001, heterogeneity P = 0.34, I²=0%], and cost [MD=-3.23 thousand yuan, 95% CI (-4.26, -2.19), P < 0.00001, heterogeneity P = 0.0003, I²=92%]. There were no statistically significant differences in overall complication rate [RR = 0.88, 95% CI (0.62, 1.23), P = 0.45, heterogeneity P = 0.11, I²=44%], overall infection event rate [RR = 0.96, 95% CI (0.36, 2.56), P = 0.93, heterogeneity P = 0.62, I²=0%] and recurrence rate [RR = 0.75, 95% CI (0.28, 1.99), P = 0.56, heterogeneity P = 0.44, I²=0%] between the two groups. The results of the TSA indicated that the observed lower seroma occurrence rate in the non-fixation group compared to the fixation group requires further validation through the inclusion of additional RCTs.ConclusionMesh non-fixation in TAPP inguinal hernia repair is deemed safe and does not elevate the risk of hernia recurrence. However, given certain limitations in this study, future comprehensive and reliable validation will require further multicenter, high-quality, large-sample double-blind RCTs.

Comparison of ilioinguial/iliohyphogastic nerves block with woundinfiltration on postoperative pain: A randomised controlled trial.

To compare postoperative pain scores at rest and on movement in patients undergoing open inguinal hernia repair between those receiving illioinguinal/illiohypogastric nerve block with ropivacaine or wound infiltration with ropivacaine. The randomised clinical trial was conducted at the Department of Anaesthesiology, Aga Khan University Hospital a tertiary care centre from March to August 2019 and comprised patients of either gender scheduled for elective unilateral open inguinal hernia repair under general anaesthesia. They were randomised into illioinguinal/illiohypogastric nerve block group A, and wound infiltration group B. In group A, 20 ml of 0.25% ropivacaine was infiltrated in the vicinity of the nerves under ultrasound guidance, while group B received wound infiltration with ropivacaine 10ml 0.25% at the end of surgery. Postoperative static and dynamic pain was assessed at 0, 2, 6, 12 and 24 hours using visual analogue scale. Total usage of opioids in 24 hours postoperatively in both groups, patient satisfaction and complications were recorded. Data was analysed using SPSS 19. Of the 60 patients, 30(50%) were in each of the 2 groups. There were 29(96.7%) males and 1(3.3%) female in group A with mean age 45.63±17.43 years, and 28(93.3%) males and 2(6.7%) females in group B with mean age 49.33±15.39. The mean pain score at rest was not significantly different between the groups (p>0.05). On movement, the mean pain score between the groups was different only at 6 hours (p=0.02). There were no significant intergroup difference in total usage of opioids in 24 hours postoperatively and patient satisfaction (p>0.05). Illioinguinal/illiohypogastric nerve block and wound infiltration with ropivacaine were found to be equally effective methods in controlling postoperative pain. NCT04462510.

Video Review Can Measure Surgical Robotic Skill Development in a Resident Robotic Hernia Curriculum: A Retrospective Cohort Study

Background: Hernia repairs are one of the most common general surgery procedures and an essential part of training for general surgery residents. The widespread incorporation of robotic hernia repairs warrants the development of a procedure-specific robotic curriculum to assist novice surgeons in improving technical skills. Objective: To evaluate a robotic hernia simulation-based curriculum for general surgery residents using video review. Methods: Retrospective cohort study of PGY-3 general surgery residents from the University of Chicago from 2019 to 2021. The residents completed inguinal hernia repair (IHR) and ventral hernia repair (VHR) drills as part of a robotic simulation curriculum. The drills were recorded and graded according to the modified objective structured assessment of technical skills (OSATS) and time to completion. The drills were completed by 3 attending surgeons to establish gold-standard benchmarks. Results: In total, 20 residents started the curriculum, 19 completed all IHR drills and 17 completed all VHR drills. Attending surgeon total OSATS scores and time to completion were significantly better than the trainees on the first attempt (P &lt; 0.05). When comparing 1st to 4th attempt, resident OSATS scores improved significantly for IHR (15.5 vs 23.3; P &lt; 0.001) and VHR (16.8 vs 23.3; P &lt; 0.001). Time also improved over 4 attempts (IHR: 28.5 vs 20.5 minutes; P &lt; 0.001 and VHR: 29.6 vs 21.2 minutes; P &lt; 0.001). Residents achieved attending-level OSATS scores by their fourth attempt for VHR, but not for IHR. Residents did not achieve attending-level times for either hernia drills. Conclusions: The robotic hernia curriculum improved resident performance on hernia repair drills and was well-received by the residents.

A Data-Driven Approach to Inguinal Hernia Repairs in Infants and Children.

Introduction: Laparoscopic inguinal hernia repair has become increasingly popular in children. The laparoscopic technique inherently assesses the contralateral processus vaginalis, reducing the risk of metachronous contralateral hernias. We hypothesized that primary laparoscopic repair would be associated with lower rates of subsequent hernia repair in the youngest patients, in whom metachronous contralateral hernias are most common. Materials and Methods: The Pediatric Health Information System database was queried for patients 0-15 years old, who underwent inguinal hernia repair between 2016 and 2022. The primary outcome was the need for subsequent hernia repair. Current Procedural Terminology (CPT) and ICD-10 procedure codes were used to determine laparoscopic versus open repair. Patients were excluded if the only recorded code was for recurrent hernia or if both laparoscopic and open codes were present for the same procedure. Results: A total of 109,456 patients were included in the study, with 20,338 patients (18.58%), undergoing laparoscopic inguinal hernia repair initially, and 2535 patients (2.32%) requiring a second hernia repair. Patients 6 months old and younger undergoing unilateral laparoscopic repair were less likely to require subsequent surgery (OR 0.82, 95% CI = 0.69-0.96). Across all ages, open bilateral repair less often required subsequent repairs (OR 1.93, 95% CI 1.48-2.51). Conclusion: Laparoscopic unilateral inguinal hernia repair decreases the need for subsequent surgical repair in infants 6 months and younger. No difference was detected in older patients. Open repair of bilateral hernias decreases the need for a second hernia operation in all age groups, suggesting that open repair is more durable.

Rise of the robots: implementing robotic surgery into the acute care surgery practice.

Acute Care Surgery (ACS) admissions and procedures are substantially increasing. ACS disproportionally accounts for a majority of morbidity and mortality among surgical patients. Minimally invasive techniques are associated with improved outcomes and shorter hospital length of stay within the ACS population. While laparoscopy is widespread, ACS surgeons have been slower to adopt the use of robotics. We aimed to evaluate the feasibility of incorporating robotic surgery within ACS practice. Robotic General Surgery operations performed by 8 Acute Care Surgeons from 5 local facilities within a large integrated healthcare system were queried over a 15 month period. Patients who underwent emergent, urgent, sub-acute, and elective robotic operations by ACS staff were identified. Demographics collected included age, gender, BMI, and ASA score. Outcomes recorded included procedure classification, total supply and implant charges (TSI), conversion to open, hospital length of stay (LOS), 30 day readmission, and 30 day mortality. Of 200 operations, the most common were Cholecystectomy (43.5%), Inguinal hernia repair (26.0%), Ventral hernia repair (18.0%), Appendectomy (5.0%), and Sigmoid Colectomy (3.5%). The median (± std dev) age was 48 ± 16.66years and BMI was 29.9 ± 8.79kg/m2. 46% of cases were sub-acute (n = 92), 33.5% were elective (n = 67), 14% were emergent (n = 28), and 6.5% were urgent (n = 13). Most patients were ASA 2 (107, 46.1%) or ASA 3 (71, 45.9%). The median (IQR) TSI and LOS were $1,770 (889.50) USD and 0.1 (0.9) days. Forty-one inpatient procedures were performed. Median LOS was 3days and expected LOS was 3.1days (O:E = 0.96). Five patients were readmitted within 30days, and there were no deaths within 30days. Robotic techniques may be safely implemented by ACS surgeons, potentially benefitting both patient and surgeon. LOS was similar between laparoscopic and robotic cases and only two cases required conversion to an open procedure. Next steps include a multi-center prospective trial comparing robotic to laparoscopic cases.

Comparing the Postoperative Analgesic Efficacy of Ketorolac and Tramadol After Open Inguinal Hernia Mesh Repair: A Randomized Controlled Trial.

Background Opioids are the mainstay for postoperative pain control. However, due to the increasing dependence on opioids and their side effects, multiple adjuncts are used to reduce opioid consumption, including non-steroidal anti-inflammatory drugs (NSAIDs). Inguinal hernia repair is one of the most common procedures performed by general surgeons worldwide. Despite various advancements in operative techniques, postoperative pain remains a major risk factor for morbidity and delayed hospital discharge following surgery. Objective The objective of this study was to compare ketorolac with tramadol for postoperative pain control following open inguinal hernia mesh repair. Methods This was a randomized controlled trial. Sixty patients undergoing unilateral primary open inguinal hernia repair with mesh were randomly divided into two groups: Group A received injection ketorolac intravenously postoperatively, while Group B received injection tramadol intravenously following surgery. Pain scores and vitals were measured at two, six, 12, and 24 hours post procedure. Other secondary outcomes included the time for nausea to stop, time to pass flatus, and time to start ambulation. Data was analyzed by independent-sample t-test using IBM SPSS Statistics for Windows, Version 30.0 (Release 2024; IBM Corp., Armonk, New York, United States); a p-value of < 0.05 was considered significant. Results Pain scores were lower in the ketorolac group when compared to tramadol. However, patients in the tramadol group had nausea for a longer duration, delayed return of bowel function, and took longer to start ambulation. There was no significant difference in vitals. Conclusion Injection ketorolac, when used in isolation, provides more effective postoperative analgesia along with fewer side effects when compared to tramadolin inguinal hernia repair.

Optimizing Urological Concurrent Robotic Multisite Surgery: Juxtaposing a Single-Center Experience and a Literature Review.

Introduction: This article juxtaposes case series with a systematic review to evaluate the feasibility, safety, and clinical outcomes of concurrent robotic multisite urological surgeries, specifically robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN), for synchronous prostate and kidney cancers. Aim: The aims of this study were to evaluate the feasibility, safety, and clinical outcomes of urological concurrent robotic multisite surgeries through a comparison of institutional findings with the existing literature. Materials and Methods: A retrospective analysis was conducted on eight institutional cases of concurrent robotic multisite surgeries performed between 2021 and 2024. The primary outcomes measured were operative time, blood loss, and postoperative complications. A systematic review of the literature was performed, searching PubMed, Embase, and Cochrane Library databases, with the last search conducted on 1 July 2024. Studies were included if they reported on concurrent robotic surgeries corresponding to the procedures performed at the institution, including RARP with RAPN, RARP with robotic transabdominal preperitoneal inguinal hernia repair (RTAPPIHR), and other multisite robotic surgeries. Risk of bias was assessed using the modified Newcastle-Ottawa Scale. Descriptive statistics were used to analyze operative time and blood loss, with confidence intervals (CIs) calculated to assess precision. Categorical variables, including postoperative complications, were summarized using frequencies and percentages. Heterogeneity was assessed using the I2 statistic, with values above 50% indicating substantial heterogeneity. A random effects model was applied when necessary, and sensitivity analyses excluded studies with high risk of bias. Results: We describe a unique docking technique employed in our procedures, which allows for atraumatic transitions between surgeries using the same port sites. Our institutional cases demonstrated the feasibility and safety of concurrent robotic multisite surgery, with a mean operative time of 315 min (95% CI: 290-340) and mean blood loss of 300 mL (95% CI: 250-350). There were no significant intraoperative complications reported. These findings are consistent with the literature, where mean operative times range from 390 to 430 min and blood loss ranges from 200 to 330 mL. Notably, no positive surgical margins or declines in postoperative renal function were observed in our cases. The systematic review included nine retrospective studies involving 40 cases of concurrent RARP and RAPN, as well as eleven studies including 392 cases of RARP combined with RTAPPIHR. The findings from these studies support the feasibility and safety of concurrent surgeries, showing similar rates of operative time, blood loss, and postoperative complications. Conclusions: Concurrent robotic multisite surgeries, such as RARP combined with RAPN or RTAPPIHR, appear to be safe and feasible. Our data suggest these procedures are non-inferior to separate surgeries in terms of safety and complication rates. Potential benefits, including reduced operative times, shorter hospital stays, and more efficient resource use, may translate into cost savings, although no formal cost-effectiveness analysis was conducted. Limitations include the small sample size, retrospective design, and lack of long-term follow-up. Prospective trials are needed to validate these findings and further refine the techniques. Funding: this review did not receive any external funding. Registration: this review was not registered in any public protocol registry due to its comparative retrospective nature.

Robotic availability, not payor status, determines access to robotic emergency general surgery hernia repair in California and Florida.

Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42-1.81, p < 0.001) compared to California. There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients.