Laparoscopic Repair Research Articles

BN SO36 - Robotic versus laparoscopic giant hiatus hernia repair - is one superior in clinical outcomes?

Abstract Background The number of robotic giant hiatal hernia repair (RGHHR) procedures is steadily increasing. RGHHR offers several potential advantages over traditional laparoscopy, including enhanced visualisation, superior ergonomics, and the use of articulating instruments, which can be particularly beneficial in the restrictive operating field of the diaphragmatic hiatus. However, the outcomes of RGHHR remain heterogeneous, both when reported alone and in comparison to laparoscopic giant hiatus hernia repair (LGHHR). This study aims to evaluate and compare the key clinical outcomes of RGHHR and LGHHR in adult patients. Method All patients undergoing primary giant hiatus hernia (GHH) surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service. Retrospective review of electronic records were utilised to document: patient demographics, hernia type, operative details. Use of mesh and gastropexy (as proxy measures to indicate difficulty of operation). Follow-up duration in weeks. Open cases within this cohort were excluded. Outcomes were: length of stay (LOS), 30-day morbidity measured using Clavien-Dindo (CD) grading, RTT and 30-day mortality. Analysis was undertaken using un-paired t-test and Chi2. A p-value of <0.05 was considered statistically significant. Results Table 1. Patients LGHHR RGHHR p n 56 29 Age (median) 71 (31-93) 66 (39-85) 0.1303 Female (%) 68.7 70 0.8988 BMI 31.8 (±6.4) 29.9 (±3.4) 0.1715 ASA grade (average) 2.4 2.2 0.0587 Hernia Types (median) 3 3 0.4411 Median follow-up (weeks) 8 (1-161) 12 (3-172) 0.5763 Table 2. Operative details LGHHR RGHHR p Mesh used (%) 9.1 0 0.0907 Gastropexy (%) 12.7 6.9 0.4175 Table 3. Outcomes LGHHR RGHHR p LOS (median) 1 (0-161) 2 (0-15) 0.4177 30-day morbidity (CD≥3, %) 3.6 6.9 0.9193 RTT (%) 9.1 6.9 0.5570 30-day mortality 0 0 NA Conclusion RGHHR approach has been successful in managing complex GHH, with low RTT, low co-morbidity and no mortality. In our institution RGHHR has demonstrated non-inferiority to LGHHR in respect to clinical outcomes. Patient factors and hernia types did not affect case selection. Use of mesh and gastropexy showed no difference in outcomes between the two groups. Cost, operative time and surgeon strain/fatigue were not evaluated in this study, however, these would provide useful additional comparative markers for the future.

A03 - BN Long Term Quality of Life Outcomes Following the Surgical Management of Complete Intrathoracic Stomach (CIS)

Abstract Background Surgery is indicated for symptomatic patients with complete intrathoracic stomach (CIS) to avoid complications (volvulus, obstruction and strangulation) associated with high morbidity. There remains limited evidence of the long-term outcomes and improvement in symptoms from this procedure. Previous large studies have been unable to compare pre-operative symptoms with their post-operative data. Although it appears the procedure has favourable outcomes, further data is required to demonstrate a significant improvement in quality of life (QoL). We therefore aim to assess the long-term outcomes, including changes to QoL and satisfaction, for patients who underwent laparoscopic biological hiatal mesh reconstruction for CIS (100%). Method Prospective data was collected from 154 consecutive GPEH (Giant Hiatus Hernia) patients intervened between March 2008- December 2023 in a large DGH. Retrospective analysis of this identified a subgroup of 34 patients with CIS. All patients underwent a laparoscopic repair with biological mesh, apart from one patient who underwent gastropexy. Outcome measures included both pre-operative and post-operative standardised GERD-Health Related Quality of Life Questionnaire (GERD-QOL) scores; complications; and patient satisfaction. Results Thirty-four patients were included (11 male:23 female) with a mean age 72 (45-83) years. All patients were symptomatic pre-operatively with heartburn (59%), dysphagia (59%), retrosternal discomfort (53%), vomiting (41%), weight loss (41%) or shortness of breath (35%). There were 4 (12%) complications and 3 (9%) 30-day mortalities. Follow up GERD-QOL questionnaires displayed 32/34 (94%) excellent scores (defined as total <5) at 6 months and 15/21 (71%) excellent scores after a median follow up of 8.5 years (72% response rate, 2 further mortalities). This demonstrated a significant improvement in scores following the procedure and long term (p<0.001). Nineteen patients (90%) were satisfied with the procedure after long term follow up (median 8.5 years). Conclusion Laparoscopic repair of complete intrathoracic stomach in this large single-centre study has demonstrated a significant improvement in symptoms and satisfaction over a median 8.5 year follow-up.

OGC SO38 - Laparoscopic repair of para-conduit hernia post minimally invasive esophagectomy using anterior hiatal suture repair and mobilisation of left liver lobe as reinforcement

Abstract Background Para-conduit hernia (PCH) formation is a rare and late complication of oesophagectomy that is associated with high risk morbidity. Minimally invasive oesophagectomy is associated with increased incidence of PCHs when compared to open or trans-hiatal oesophagectomies. Various techniques to repair PCHs including mesh repair, anterior/posterior hiatal suture repairs or even careful 360 degree repairs have been described in the literature1,2. But the risk of recurrence of PCH still remains high. We describe a unique laparoscopic technique which we believe to be associated with reduced risk of recurrence of PCH post-surgical repair. Method We present 4 cases of symptomatic PCH repairs performed laparoscopically. In this unique technique the contents of the sac is reduced and the hiatus is repaired anteriorly with interrupted ethibond sutures. The left lobe of the liver is mobilised and glued to the greater curve omentum along the conduit and the hiatus. This latter step is an additional way of preventing intraabdominal contents from entering the mediastinum. Data was collected retrospectively to include: patient demographics, details of original MIO surgery, pre-op imaging and details of the presenting symptoms with PCH including imaging, operative details and all available follow up. Results Between January 2022 and July 2024, 4 patients underwent laparoscopic repair of paraconduit hernia within 1-2 years post MIO. 3 were male and 1 female aged between 56-71 years. 3 of the procedures were performed electively and one as an emergency. All presented with symptomatic paraconduit hernias and managed with surgery using the technique described above. We present a video of laparoscopic repair as described. Conclusion We report a case series of 4 patients presenting with symptomatic PCH that were managed safely with a unique laparoscopic technique using suture repair and left liver lobe mobilisation to prevent recurrence of PCH.

ORGAN-SPARING AND ORGAN- REMOVING SURGICAL PROCEDURES FOR PATHOLOGICAL CONDITIONS OF THE SPLEEN IN CHILDREN. QUESTIONS AND ANSWERS.

Introduction. Nowadays splenic surgery is a rather urgent problem in pediatric surgery. There are diseases where only splenectomy allows a child to live a full life. These are: sickle cell anemia (SCA), idiopathic thrombocytopenic purpura, hereditary spherocytosis (Minkowski- Chauff ard disease), thalassemia, and autoimmune hemolytic anemia. The spleen is involved in 25-30 % of cases of blunt abdominal trauma in children. The loss of more than 45 % of the circulating blood volume leads to an unstable hemodynamic state in the child. The question of surgical treatment and preservation of the spleen in hemoperitoneum due to its injury is of vital importance. Aim: To study the possibilities of surgical treatment of diseases and injuries of the spleen in children. Materials and methods. An analysis of surgical interventions for diseases and injuries of the spleen in children aged 2 to 17 years from 2019 to 2024 was performed. The study was conducted in the surgical departments of the «Clinical Center of Pediatric Medicine» of the «Okhmatdyt Hospital» of the «Western Ukrainian Specialized Center» (Lviv) and the «Chernivtsi City Children’s Clinical Hospital» (Chernivtsi). 27 children (17 girls, 10 boys) had spleen diseases and 43 children (23 girls, 20 boys) had spleen injuries. Splenectomy was performed for the following splenic diseases: sickle cell anemia (9 children), idiopathic thrombocytopenic purpura (4 children), hereditary spherocytosis (Minkowski- Chauff ard disease) (6 children), thalassemia (1 child), and autoimmune hemolytic anemia (1 child). Six children had splenic cysts: 3 children had posttraumatic cysts and 3 children had parasitic cysts. Twenty children underwent surgery for splenic injuries. The following surgical procedures were performed: laparoscopic abdominal cavity repair with spleen preservation followed by conservative therapy (13 children); laparoscopic splenectomy (2 children); laparotomy, splenic suture (2 children); and open splenectomy (3 children).Results. Conservative management of splenic injuries of varying degrees according to the American Association for the Surgery of Trauma (AAST) was performed in 23 (53.49 %) children. Resorption of hemoperitoneum in cases of conservative treatment of splenic injuries occurred 11-14 days after the start of treatment. Safe, full physical activity was resumed after 6 weeks of conservative treatment of splenic injury. Surgical procedures were performed in 20 (46.51 %) children using various techniques. 17 patients underwent laparoscopy. 2 children underwent laparoscopic splenectomy for grade IV AAST injury and hemodynamic instability. In 15 cases, treatment was started with conservative therapy, but during monitoring an increase in hemoperitoneum was observed, indicating the need for laparoscopy. Laparoscopy was performed in 13 children. A minimum of 100 ml and a maximum of 400 ml of blood was collected laparoscopically in the children. The abdominal cavity was examined and hemostasis was confi rmed. In cases where the spleen was «wrapped» with the omentum, the omentum was not separated from the spleen. The operation was completed by placing a drainage tube in the perisplenic space. In 2 children, grade IV AAST injuries were converted to an open procedure in which the spleen was sutured to stop bleeding and a drain was left near the splenic bed. Grade V AAST splenic injury in 3 children was an indication for left subcostal laparotomy and splenectomy. For splenic disease, laparoscopic splenectomy was performed in 12 (44.44 %) children, with high effi cacy in Minkowski- Chauff ard disease combined with gallstones (3 children) where simultaneous cholecystectomy was possible. Laparoscopic removal of splenic cysts was also justifi ed in 3 (11.11 %) children. However, removal of parasitic cysts required open splenectomy in 3 patients. Open splenectomy was performed in 9 children with splenic disease. In 5 children the inappropriateness of laparoscopy was due to severe perisplenitis, large spleen weight and young age of the children.Conclusions1. The morpho- functional structure of the spleen promotes spontaneous hemostasis, which is the basis for conservative treatment of spleen injuries in 53.49 % of children.2. The AAST classifi cation of splenic injuries from grade I to V, hemodynamic indicators and ultrasound monitoring of blood in the abdominal cavity can be used as a basis for choosing the method of treatment of closed blunt splenic injuries in children.3. Ineff ectiveness of conservative treatment, hemodynamic instability and increase of blood in the abdominal cavity in a child with splenic injury within 4 hours is an indication for laparoscopy.4. Splenic suturing and laparoscopic monitoring should be the preferred methods for treating closed splenic injuries in children to preserve the organ.5. The choice of surgical intervention for splenic diseases in children should be individualized and depend on the disease, the child’s age, the size of the spleen, and the presence of complications of the disease.

Laparoscopic transabdominal vs. totally extraperitoneal inguinal hernia repair: outcomes, healthcare utilization, and cost differences.

Laparoscopic inguinal hernia repair utilizes either a transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approach. The literature remains mixed on outcomes comparing TAPP versus TEP. The objective of our study was to assess outcomes, healthcare utilization, and cost differences between TAPP and TEP inguinal hernia repair. Adult patients who underwent elective inguinal hernia repair between 2013 and 2021 were retrospectively identified from our institution's electronic health record. Baseline characteristics and postoperative complications were compared using chi-squared test. Multivariable logistic regression was used to model the odds of experiencing a postoperative emergency department visit, readmission, and/or reoperation within 6months were surgery. Generalized linear models were used to investigate differences in cost between TAPP and TEP groups. 1086 patients underwent TAPP repair, while 1277 patients underwent TEP repair. TAPP patients had more than double the rates of readmissions (3.1% vs. 1.3%, p = 0.002) and reoperations (1.5% vs. 0.2%, p = 0.001) within 6months of surgery. On multivariable analysis, undergoing TAPP inguinal hernia repair was associated with higher odds of reoperations and/or readmissions within 6months of surgery (OR 2.8, CI [1.5, 5.1], p = 0.001). TAPP repair had a higher index surgery cost and higher costs associated with reoperations and readmissions compared to TEP repair. Although both approaches are very safe, TAPP inguinal hernia repair had higher rates of postoperative complications, increased healthcare utilization, and higher associated costs. Future studies should be directed toward decreasing postoperative healthcare utilization in order to decrease costs in inguinal hernia repair.

MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia

Abstract Background Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population. The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia. Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility. Method Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic. She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome. This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA. Results Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy. Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying. Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery. Conclusion Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures. Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions. Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.

BN SO28 - Dual Mesh Technique in Revisional Complex Laparoscopic Repair of Recurrent Paraesophageal Hernia (PEH)

Abstract Background Mesh Augmentation in laparoscopic repair of complex PEH has been an ongoing debate with regards to its risk profile and success rate in reducing hernia recurrence.1 There have been concerns regarding the deployment of non-absorbable mesh around the hiatus resulting in erosion and stricture, which may lead to oesophagectomy or gastrectomy.2 Absorbable mesh has been introduced with appealing advantages of lower mesh-related morbidities, however its high cost and unclear long-term durability remains questionable for its role as an ideal mesh.2 Method This is the case of a 65-year-old patient with chronic reflux symptoms undergoing revisional complex laparoscopic repair of recurrent type 4 PEH. The focus of this video is using a dual mesh technique involving fixation of a non-absorbable synthetic mesh at least 15mm from the oesophageal wall, reinforced with placement of an absorbable biosynthetic mesh which is in contact with the hiatus boundary. Results With regards to position of the permanent synthetic mesh, direct contact with the oesophagogastric wall should be avoided due to complications secondary to erosions and strictures. The deployment of a second mesh of absorbable material is preferred in this patient for hiatal reinforcement to reduce risk of recurrence due to friability of adjacent tissues. Conclusion The dual mesh technique aims to overcome the limitations of both types of mesh materials while preserving their individual benefits, expectantly reducing recurrence.

BN SO62 - Laparoscopic technique for right sided paraduodenal hernia repair: A clinical study and surgical insights

Abstract Background Paraduodenal hernias can present significant diagnostic and therapeutic challenges, with up to 50% potentially leading to bowel obstruction. A minimally invasive approach to repairing these defects offers reduced morbidity and quicker recovery. This report highlights the feasibility and safety of laparoscopic repair of a right-sided paraduodenal hernia. Method A 19-year-old female presented with persistent postprandial bilious vomiting and a long history of forceful regurgitation 10-30 minutes after eating. The preoperative evaluation, surgical technique and operative outcomes are detailed. Results Preoperative evaluation included magnetic resonance imaging, computed tomography and a barium swallow, revealing an incidental finding of the duodenojejunal flexure and most jejunal loops on the right side of the abdomen. A right paraduodenal hernia was diagnosed during laparoscopy. After delineating and reducing the hernia laparoscopically, the sac was obliterated by opening up the posterior aspect over the inferior vena cava. The repair was completed by suturing the hernia orifice and plicating the duodenum. The patient's symptoms resolved postoperatively, with no intraoperative or immediate postoperative adverse outcomes reported. Scheduled outpatient follow-up showed satisfactory resolution of symptoms. Conclusion The laparoscopic repair of the right paraduodenal hernia was successfully performed, leading to the resolution of the patient's symptoms. This case underscores the importance of considering laparoscopic approaches for managing complex and rare hernias, especially when cross-sectional imaging modalities do not clearly identify the cause of symptoms. The laparoscopic technique offers significant advantages, including reduced pain and faster recovery.

The enhanced-view totally extraperitoneal repair of abdominal bulge after DIEP flap breast reconstruction for breast cancer: a case report.

The deep inferior epigastric perforator (DIEP) flap for autologous breast reconstruction is associated with higher patient satisfaction and fewer abdominal morbidities at the donor site than the transverse rectus abdominis myocutaneous flap. However, abdominal bulging occurs at a certain frequency, and there is no established treatment. Here, we present a case of laparoscopic hernia repair using the enhanced-view totally extraperitoneal (eTEP) method in a patient with a lower abdominal bulge after DIEP flap reconstruction. A 53-year-old woman underwent left nipple-sparing mastectomy, left axillary lymph node dissection, and breast reconstruction with a DIEP flap for left breast cancer 3years previously. We performed an eTEP method for an abdominal bulge. The absence of a hernia sac facilitated dissection of the retrorectal space, and a left-sided transversus abdominis release was performed, followed by mesh placement. No postoperative abdominal bulging was observed. Using the eTEP method for repairing an abdominal bulge after DIEP flap reconstruction is advantageous because it facilitates a relatively straightforward dissection of a wide area of the retrorectal space without a hernia sac.

Primary abandon-of-the-sac technique in laparoscopic inguinoscrotal hernia repair: A retrospective comparative study

Abstract BACKGROUND: Laparoscopic inguinoscrotal hernia repair is a challenging procedure. The surgeon must perform large dissections to reduce the hernial sac, although he has the alternative technique of leaving the sac at the deep inguinal orifice level from the beginning. OBJECTIVE: We aimed to determine the postoperative morbidity of laparoscopic inguinoscrotal hernia repair with the primary abandon-of-the-sac (PAS) technique and to compare it with complete dissection and reduction (CD). Operative times were compared as a secondary outcome. METHODS: A retrospective analysis was conducted between January 2021 and May 2022. The minimum follow-up was 3 months. Postoperative morbidity and operative times in the PAS group were analyzed and compared with those in the CD group. RESULTS: Seventy-eight patients were evaluated. The mean follow-up was 5 months (range, 3–18 months). PAS was performed in 15 patients, while the remaining 63 patients underwent CD. There were no significant differences in demographic and hernia characteristics. An overall morbidity of 30.7% was recorded. No statistical differences were observed in postoperative morbidity between the PAS group and the CD group (33.3% vs. 30.1%; P = 0.81). No statistical differences were found in terms of seromas (13.3% vs. 9.5%; P = 0.662), hematomas (6.6% vs. 9.5%; P = 0.727), or hydrocele (13.3% vs. 11.1%; P = 0.808). No recurrence or chronic pain was observed during the study period. Finally, a significantly shorter median operative time was recorded in the PAS group (50 vs. 80 min; P = 0.0026). CONCLUSION: The PAS technique is safe and feasible for the management of inguinoscrotal hernias. In our series, comparable morbidity rates were found when comparing it with CD. The benefit of the PAS technique is a significant reduction in operative time, despite the fact that it requires more postoperative ultrasounds.

Ureteroinguinal hernia: an added advantage for laparoscopy in the management of inguinal hernia—a case report

Different abdominal organs can herniate into the inguinal canal, including the small bowel, colon, appendix, ovaries, and, less commonly, the urinary bladder and fallopian tubes. Herniation of the ureter within an inguinal hernia is a very rare occurrence. To the best of our knowledge, less than 150 cases have been reported in the literature, including only 15 pediatric cases. A 3-month-old boy presented to our clinic with a left inguinal swelling. Ultrasound of the abdomen and pelvis showed grade 4 left hydronephrosis with a dilated tortuous ureter passing through the left inguinal canal. Further investigation revealed that the patient had a left primary obstructing megaureter with a ureteroinguinal hernia. The case was managed with laparoscopic repair of the inguinal hernia and urethrostomy. The current case proves an additional advantage for laparoscopy as it allows proper visualization of the anatomy and identification of atypical hernias, such as ureteroinguinal hernia.

A retrospective nationwide comparison of laparoscopic vs open inguinal hernia repair in children

BackgroundUtilization of the laparoscopic approach for inguinal hernia repair has increased significantly over the past decade. The purpose of this study is to compare rates of second hernia operation and same side recurrence following open and laparoscopic inguinal hernia repair in a large national cohort. MethodsThis retrospective analysis utilized the Pediatric Health Information System database to identify children <18 years-old who underwent laparoscopic or open primary inguinal hernia repair from 2017-2021. Data were collected through 2022 to allow minimum one year follow-up. Second hernia operation rates, inclusive of same side recurrence and metachronous contralateral hernia, and same side recurrence rates were compared by multivariable mixed effects model controlling for confounders and institutional clustering. Misclassification rates were determined through data validation at four constituent institutions. Sensitivity analyses determined true outcome rates. ResultsWe identified 53,287 operations (15.6% laparoscopic). Rate of second hernia operation was greater following laparoscopic repair (2.9% vs 2.6%, p=0.04) with no difference on multivariable analysis (OR 1.14, 95% CI 0.98-1.32). Same side recurrence rate was greater following laparoscopic repair (1.5% vs 0.4%, p<0.001) which persisted on multivariable analysis (OR 3.72, 95% CI 2.90-4.78). Sensitivity analysis demonstrated true laparoscopic and open repair rates of 14.2% and 85.8%, respectively. True rates of second hernia operation and same side recurrence were identical to those determined by PHIS. ConclusionLaparoscopic inguinal hernia repair in children has more than three times the odds of same side hernia recurrence than open repair which is balanced by a reduced rate of second operation for metachronous hernia. Level of EvidenceTreatment Study – Level III

A study of comparison of perioperative complications in intraperitoneal onlay mesh technique vs extended view totally extraperitoneal ventral hernia repair

Background: Abdominal hernia occurs through the layers of the abdominal wall at a weak point. Laparoscopic ventral hernia repair (LVHR) is an established treatment for ventral hernias. This study was conducted in patients who underwent e-TEP and IPOM surgery for ventral hernia to characterize postoperative pain, recovery time, and quality of life. Predefined preoperative and peri-operative factors were examined for their potential impact. Methods: A prospective study on a total of 50 patients who underwent IPOM and e-TEP for ventral hernia was conducted, who fulfilled the inclusion criteria. Patients were randomized by simple random sampling technique and were divided into two groups of 25 each (Group A- e-TEP and Group B- IPOM). Data of both groups were compared and analysed for statistical significance using Chi square test and Student ‘t’ test. Results: The eTEP approach provides benefits compared to IPOM in terms of reduced hospital stay, earlier return to work and cost effective. However, eTEP is linked to complex learning process and in the end the decision of the surgery type should be made on the basis of specific patient’s conditions, surgeon’s expertise and availability of resources Conclusions: In study we found that both surgeries were comparable, with each having some benefits over the other.

Surgical Outcomes after Laparoscopic Repairs of Para-colostomy Hernia and Para-ileal-conduit Hernia: A Comparative Study.

The aim of the study was to investigate the differences in clinical characteristics and surgical outcomes between para-colostomy hernia (PCH) and para-ileal-conduit hernia (PICH) after laparoscopic repairs. We retrospectively analyzed data from 41 laparoscopic parastomal hernia repairs performed at the Jikei University Daisan Hospital between June 2012 and September 2023. The data were divided into PCH (n=31) and PICH (n=10) groups and compared. The comparison of patient backgrounds and hernia characteristics showed no significant differences between PCH and PICH groups. Surgical procedures included laparoscopic Sugarbaker repair (LSB) for PCH (29 cases) and PICH (8 cases), and endoscopic Pauli repair (ePauli) for both PCH (2 cases) and PICH (2 cases). Intraoperative findings indicated a significantly higher rate of severe intra-abdominal adhesions (Zühlke index III/IV) in the PICH group (60%) compared to the PCH group (23%) (p=0.0485). The median operation time was significantly longer for PICH (223 [120-423] minutes) than for PCH (158 [48-386] minutes) (p=0.0467). Perioperative complications occurred in 1 PCH case (3%) and 2 PICH cases (20%), with no significant difference in postoperative hospital stay (9 [4-19] vs. 9 [6-14] days). With the follow-up period of 57 [2-110] months for PCH and 52 [20-104] months for PICH, recurrence was observed in 4 PCH cases (12%) but not statistically significant. The comparison of PCH and PICH suggests that PICH is associated with more severe intra-abdominal adhesions and longer operation times, indicating higher operative difficulty. Therefore, it would be advisable to discuss the surgical outcomes of repair for these stomas separately.

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.

Surgical treatment of cesarean scar pregnancy based on the three-category system: a retrospective analysis

BackgroundCesarean scar pregnancy (CSP), a distinct form of ectopic pregnancy, presents challenges in effective management. It is categorized into three subtypes according to the location of placental implantation and the thickness of the myometrium at the uterine scar. Nevertheless, the optimal choice of treatment modalities for these subtypes remains largely unexamined.MethodsIn this retrospective analysis, we investigated the cases of 130 patients diagnosed with CSP who underwent diverse treatment approaches, namely ultrasound-guided dilation and curettage (D&C), hysteroscopic surgery alone or in combination with laparoscopic surgery (HCoLC), or uterine artery embolization (UAE) followed by curettage. Clinical data were meticulously retrieved from medical records and follow-up data, and a comparative analysis of relevant indicators was carried out across the different CSP subtypes.ResultsFrom January 2017 to December 2021, 35 patients underwent D&C, 85 underwent HCoLC, and 10 received UAE as a pretreatment. In the D&C group, the success rates for Type I and Type II CSP were 64.29% (18/28) and 14.28% (1/7), respectively. Significant differences were observed between the success and failure groups in terms of gestational sac size and clinical classification. Compared to Type I CSP, Type II CSP exhibited significantly longer surgical durations and higher hospitalization costs (P < 0.05). Three patients classified as Type III underwent simultaneous hysteroscopic evacuation of cesarean scar pregnancy and laparoscopic repair of the cesarean scar defect, achieving a 100% success rate in their initial treatment. HCoLC showed no significant differences in surgical duration and hospitalization costs but had higher success rates and shorter hospital stays compared to the D&C and UAE groups (P < 0.05). The UAE group had significantly longer surgical durations, higher hospitalization costs, and a higher incidence of postoperative complications (P < 0.05). However, these factors did not result in improved surgical success rates.ConclusionThe classification of CSP and the measurement of gestational sac are of crucial importance in determining the most appropriate surgical intervention strategy. For patients diagnosed with Type I CSP, D&C and hysteroscopy are reliable treatment choices. In cases with larger gestational sacs or Type II CSP, hysteroscopy, either alone or in combination with laparoscopy, is regarded as a reliable and effective treatment approach. In patients with type III CSP, lesion excision with uterine repair is the recommended treatment.

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.

Long-term patient reported outcomes after robotic, laparoscopic, and open ventral hernia repair.

Current evidence demonstrates questionable incremental benefit of robotic abdominal wall (ventral) hernia repair when compared to other approaches. However, data are mainly limited to 30-day outcomes and do not capture long-term patient reported outcomes (PROs) where the robotic may provide distinct advantages. We analyzed patients who underwent ventral hernia repair from January 2020-September 30, 2022 in the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR). Validated PROs included the Ventral Hernia Recurrence Inventory (VHRI), PROMIS Pain Intensity 3a (Pain 3a), and HerQLes quality of life measures. Survey weighting was employed to reduce non-response bias and balance respondents with the overall COHR population. Logistic regression was used to assess the relationship of operative approach with answering "Yes" to the 3 VHRI questions, reporting a worse than average Pain 3a score, and reporting a below median HerQLes score. Models accounted for patient, hernia, and operative characteristics. Our sample included 1583 patients undergoing hernia repair, of which 507 (32.0%) were robotic, 202 (12.8%) were laparoscopic, and 874 (55.2%) were open. Median follow up time was 1.3years (IQR 1.2-1.5). Patient characteristics were similar across approaches. Robotic repairs were more often performed electively, on larger hernias, and with mesh. After controlling for covariates, a robotic approach was associated with a lower predicted probability of reporting a bulge [19.5% (95% CI 15.7-23.2%)] than a laparoscopic approach [26.8% (95% CI 20.4-33.2%)], but was no different than an open approach [18.8% (95% CI 16.1-21.6%)]. No other differences in PROs were found by approach. We found a lower likelihood of reporting a bulge after robotic ventral hernia repair when compared with a laparoscopic approach, but no difference when compared with an open approach. No other differences in long-term PROs were found when comparing robotic to laparoscopic or open approaches.

Laparoscopic repair of gastric conduit obstruction after robot-assisted minimally invasive esophagectomy: a case report

BackgroundGastric conduit obstruction (GCO) is a known complication after esophagectomy. Laparoscopic revision surgery for GCO is relatively rare, with limited reports in the literature. Here, we report a case of GCO after robot-assisted subtotal esophagectomy and posterior mediastinal gastric conduit reconstruction, which was successfully repaired laparoscopically.Case presentationA 66-year-old man presented with a passage disorder that became noticeable 14 months after surgery. Fluid passage was difficult, and the patient opted for revision surgery. The conduit had entered and deflected into the mediastinum; it also twisted due to band formation. The revision surgery was performed laparoscopically through five ports. The bands were dissected, esophageal hiatus was sutured, and conduit re-fixed. The intraoperative endoscopy was used to confirm that the obstruction had been released. The lack of adhesion of the posterior half of the gastric conduit wall, combined with postoperative weight loss leading to a decrease in omental volume, as well as inadequate fixation during the initial surgery, are believed to have contributed to the ease of the conduit deviation into the intrathoracic cavity. In addition, the twisting of the conduit due to band formation exacerbated the obstruction.ConclusionsLaparoscopic revision surgery may become an effective treatment option as the number of minimally invasive esophagectomies is expected to increase in the future. Furthermore, the fixation method during initial surgery should be carefully considered and optimized to prevent gastric conduit obstruction. Additionally, the use of intraoperative endoscopy to evaluate the lumen of the conduit during surgery proved beneficial in this case, highlighting its potential value in identifying and addressing obstruction.