Transversus Abdominis Release Research Articles

Open versus robotic transversus abdominis release for ventral hernia repair: an updated systematic review, meta-analysis, and meta-regression.

Posterior component separation using transversus abdominis release (TAR) is well established as an option for repair of large hernia defects. TAR can be performed robotically (rTAR) or open (oTAR) with limited data to demonstrate benefit and guide decision making. We conducted a systematic review and meta-analysis comparing rTAR and oTAR approaches for ventral hernia repair (VHR). We searched Pubmed, Embase, Cochrane, and Web of Science for studies comparing rTAR and oTAR for VHR. Hybrid rTAR was not included in our analysis. Our primary outcomes were overall postoperative and intraoperative complications, surgical site occurrences (SSO), SSO requiring surgical intervention (SSOPI), surgical site infection (SSI) superficial or deep, and fascial closure. Additional outcomes were operative time (OT), readmission, length of hospital stay (LOS). We performed sensitivity analysis to explore reasons for heterogeneity and outliers, and a proportional meta-analysis of conversion during rTAR. We performed a meta-regression exploring the relationship of BMI, hernia defect and mesh width rTAR/oTAR with the analyzed outcome within each study. 503 studies were screened and seven studies were included in this analysis. Our sample totaled 780 patients, of which 298 (38.2%) underwent rTAR. Defect width ranged between 8.7 to 13.5cm (cm) for rTAR and 10 to 13.5cm for oTAR. Mean mesh area ranged from 66.9 to 980cm2 and from 51.3 to 1344cm2 for rTAR and oTAR respectively. We found lower overall complications (9% versus 24.6%; RR 0.43; 95% CI 0.26 to 0.73; P < 0.01) and intraoperative complication (5.9% versus 9.1%; RR 0.44; 95% CI 0.22 to 0.88; P = 0.02) rates for the rTAR group. There was no difference in fascial closure between the groups (99% versus 94.6%; RR 1.05; 95% CI 0.99 to 1.11; P = 0.11). rTAR presented lower SSI rates (2.5% versus 7.8%; RR 0.33; 95% CI 0.13 to 0.8; P = 0.01). No differences were found in SSO (16.3% versus 13.7%; RR 0.87; 95% CI 0.51 to 1.48; P = 0.6) or SSOPI (5.4% versus 8.9%%; RR 0.5; 95% CI 0.22 to 1.15; P = 0.1) rates. No statistically significant differences were found in superficial SSI (0.76% versus 3%; RR 0.36; 95% CI 0.07 to 1.75; P = 0.21) and deep SSI (0% versus 4.2%; RR 0.23; 95% CI 0.02 to 3.12; P = 0.27). Open surgery presented a lower OT (MD -67.7min; P < 0.001), but robotic surgery showed a reduced LOS (-3.9days; 95% CI -4.8 to -3.1; P < 0.001). No differences were found in readmission and 1year recurrence rates. The proportional meta-analysis showed a conversion to open rate of 6.4 per 100 patients (95% CI 3.3 to 12 patients) during rTAR. Meta-regression presented no statistically significant influences of rTAR/oTAR mesh width and defect width relations and BMI, despite the analysis was limited by the low number of studies. Robotic TAR may be associated with lower intraoperative and postoperative complications, lower SSI, shorter LOS, and longer operative times when compared to oTAR. Given the limitations of the included studies, randomized trials are needed to better evaluate the impact of the robotic-assisted surgery for complex abdominal wall reconstruction. CRD42024540991.

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.

The impact of diabetes and presurgical glycemic control on wound morbidity following open complex abdominal wall reconstruction: a single-center experience.

Numerous studies have identified diabetes mellites (DM) as a significant risk factor for postoperative wound morbidity, with suboptimal preoperative glycemic control (GC) posing an even greater risk. However, this data largely excludes ventral hernia patients. Our study examined the association between diabetes and preoperative GC and postoperative outcomes following open complex abdominal wall reconstruction (AWR). We identified diabetic patients who had undergone open, elective, clean VHR with transversus abdominis release (TAR) and permanent synthetic mesh at the Cleveland Clinic Foundation between January 2014 and December 2023. Their 30-day outcomes were compared to non-diabetic patients undergoing the same procedure. Subsequently, diabetic patients were categorized based on GC. status: "Optimal GC" (HbA1c < 7%), "Sub-optimal GC" (HbA1c 7-8.4%), and "Poor GC" (HbA1c ≥ 8.5%) and their outcomes were compared. 514 patients with DM who underwent clean elective TAR were identified, of which 431 met the inclusion criteria. GC was deemed optimal in 255 patients, sub-optimal in 128, and poor in 48 patients. Demographics were similar, except for anticoagulation treatment (p = 0.014). The entire study population exhibited significantly higher rates of wound morbidities and overall complications compared to non-diabetic patients. However, rates of surgical site infection (SSI), surgical site occurrence (SSO), SSO requiring procedural intervention (SSOPI), and reoperation did not differ significantly among the three cohorts of presurgical glycemic control (p = 0.82, p = 0.46, p = 0.51, p = 0.78), respectively. No occurrence of mesh removal was documented. In general, diabetes is a marker for increased wound morbidity and complications following complex abdominal wall reconstruction. However, we could not establish a hard cutoff to justify withholding surgery in symptomatic patients based on an arbitrary HbA1C level. We believe this data is important for shared decision-making when considering AWR for symptomatic ventral hernias in diabetic patients.

WP1.6 - Intraoperative fascial traction for the treatment of large hernias - results of a multicentre study

Abstract Background The incidence of incisional hernias after median laparotomy is about 20%. Intraoperative fascial traction (IFT) is a new technique for treatment of large hernias. Materials and methods In this study data from five hospitals using IFT between 12/2020 and 9/2023 was analysed. In all cases the Fasciotens®Hernia System was applied. When fascia closure was not possible, transversus abdominis release (TAR) was performed. All patients underwent a standardized clinical and ultrasound examination during follow-up. Quality of life was assessed using the HerQLes questionnaire. Results A total of 96 patients were included in the study (HH-62, DA-11, SB-10, D-9, L-4). The age was 59.9±14.1 years, 41% were female, BMI was 31.0±7.3kg/m², hernia width was 15.7±5.1cm. 88.5% underwent pretreatment with botulinum toxin (BTX). A TAR was performed in 28.1% cases. Bridging was necessary in 5.2%. Length of stay was 8.3 days. In the postoperative course, 39/96 (40.6%) patients experienced a complication: 20.8% seroma, 9.4% wound infection, 4.2% haematoma, 2.1% intestinal injury, 1.0% wound dehiscence, 3.1% pneumonia and 2.1% urinary tract infection. No patient died. The incidence of wound infections was higher in patients with additional TAR (11.1% vs. 8.7%). During the mean follow-up of 15.7±12.6 months 2 hernias at the border of the mesh were recognized. The HerQLes summary score was 64.5. Conclusion This multicentre study shows a low incidence of wound infection and recurrences using IFT. The fascia closure rate is high when combining IFT with BTX pretreatment. Further randomised studies of IFT should follow to support these data.

Robotic Pauli repair of parastomal hernia.

Robotic retro-muscular mesh repair of parastomal hernia (PH) is possible with transversus abdominis release. The aim of this study is to report mid-term results with this method. Patients who underwent surgery for PH were enrolled in a prospective study. Patients with concomitant midline hernia also underwent Rives repair. Polypropylene meshes with an absorbable buffer mesh were used in the retro-muscular pocket-except PTFE was chosen for inflammatory bowel disease patients. Follow-up was by telephone and physical examination and CT if suspicion of complication. Of the 56 included ostomy patients, 44 had colostomies, 10 had ileostomies, and two had urostomies. Thirty-nine percent had a concomitant hernia, and 25% had recurrent PH. The mean operating time without accessory repair was 156min (SD 37), and with accessory repairs 220min (SD 62). One bowel lesion and one vascular injury to the stoma occurred, prompting intraoperative stoma revision without postoperative morbidity. Postoperative complications ensued in 12 patients (23%). One patient had stoma necrosis after 3weeks and the stoma was relocated. One patient had a mesh infection, 3 patients temporary ileus, one patient hypovolemic renal failure, and two patients experienced a flare-up of their Crohn's Disease. One parastomal abscess was drained percutaneously. The median postoperative stay was 3days (1-21; mean 3.7days), and the readmission rate was 8.9%. The recurrence rate at mean and median 24months follow-up is 5.4%, two in ileostomy patients and one colostomy patient with unaltered bulging where CT shows a relatively large prolapse and recorded as a failure. Robotic Pauli repair has shown promising results. However, repair fails of PH at small bowel ostomies with short mesentery. ePauli/TAR is now the preliminary choice for eligible patients at our site. Comparative studies with the intraperitoneal mesh standard are needed.

Elective complex ventral hernia repair in contaminated fields: A propensity score–matched analysis of long-term quality of life and outcomes between different prostheses

BackgroundRandomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain. MethodsThe Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II–IV) ventral hernia repair (2013–2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh. ResultsA total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53–70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12–25) and 13 cm (IQR 8–16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups. ConclusionIn the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.

Early outcomes of robotic modified retromuscular Sugarbaker technique for end colostomy parastomal hernia repair.

The modified retromuscular Sugarbaker or Pauli technique is a technique for parastomal hernia repair, which requires the dissection of the retromuscular space and a transversus abdominis release for stoma lateralization and placement of a retromuscular mesh. Given the limited evidence regarding the robotic approach to this technique, this study aims to evaluate the outcomes of this newly introduced procedure, focusing on the rate of 30-day complications and recurrence rates. Retrospective case series report. Patients included underwent an elective robotic modified retromuscular Sugarbaker technique for the repair of a parastomal hernia associated with an end colostomy. All surgeries were performed at a tertiary referral center from September 2020 to December 2023. A total of 21 patients underwent a robotic modified retromuscular Sugarbaker in our study. The parastomal hernias operated on were classified according to the European Hernia Society as 9.5% (2/21) type I, 52.4% (11/21) type II, 23.8% (5/21) type III, 14.3% (3/21) type IV. Early complications observed included 14.3% (3/21) seroma, 9.5% (2/21) surgical site infection, 19% (4/21) postoperative ileus, and one case of large bowel obstruction due to colitis (4.8%), which was managed conservatively. No Clavien-Dindo grade III complications were reported. The overall recurrence rate was 9.5% (2/21) with a median follow-up of 12.5 months (IQR: 3.9-21.3). Both recurrences occurred during the early phases of the learning curve and were possibly attributed to insufficient lateralization of the stoma. Robotic modified retromuscular Sugarbaker for parastomal hernia repair is a challenging procedure with promising early outcomes.

Outcomes after open posterior component separation via transversus abdominis release (TAR) for incisional hernia repair. A systematic review and meta-analysis.

Given its potential advantages, open Transversus Abdominis Release (oTAR) has been proposed as a durable solution for complex AWR. However, its applicability in different scenarios remains uncertain. We aimed to analyze the current available evidence and determine surgical outcomes after oTAR. We performed a systematic electronic search on oTAR in PubMed/Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Postoperative morbidity and recurrence rates were included as primary endpoints and Quality of life (QoL) was included as secondary endpoint. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) between all studies. A total of 22 studies with 4,910 patients undergoing oTAR were included for analysis. Mean hernia defect and mesh area were 394 (140-622) cm2 and 1065 (557-2206) cm2, respectively. Mean follow-up was 19.7 (1-32) months. The weighted pooled proportion of recurrence, overall morbidity, surgical site occurrences (SSO), surgical site infection (SSI), surgical site occurrences requiring procedural intervention (SSOPI), major morbidity and mortality were: 6% (95% CI, 3-10%), 34% (95% CI, 26-43%), 22% (95% CI, 16-29%), 11% (95% CI, 8-16%), 4% (95% CI, 3-7%), 6% (95% CI, 4-10%) and 1% (95% CI, 1-2%), respectively. A significant improvement in QoL after oTAR was reported among studies. Open TAR is an effective technique for complex ventral hernias as it is associated with low recurrence rate and a significant improvement in QoL. However, the relatively high morbidity rates observed emphasize the necessity of further patients' selection and optimization to improve outcomes.

Modified Chevrel Technique: A Lifesaver for Surgeons.

Background and Objectives: Ventral hernias (VH) pose significant challenges for surgeons due to the risk of recurrence, complexities in aligning abdominal muscles, and selecting the most suitable layer for mesh augmentation. This study aims to evaluate the effectiveness of utilizing the anterior rectus fascia as a turnover flap in conjunction with onlay mesh reinforcement, a procedure known as the modified Chevrel technique (MCT). Materials and Methods: We conducted a retrospective analysis of patients who were operated on using MCT for abdominal hernias between January 2013 and December 2019. Data were extracted from our hospital's electronic database. Recurrence rates, as well as the rates of surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrences requiring procedural intervention (SSOPI), were analyzed based on patients' comorbidities and demographic characteristics. Results: The median follow-up period was 42.9 months (range: 14-96), and the recurrence rate was 4% (n = 3). Among the recurrent cases, three patients had chronic obstructive pulmonary disease, representing a statistically significant association (p = 0.02). Although all patients with recurrence were obese, this association did not reach statistical significance (p > 0.05). The mean hospitalization duration was 17.6 days (range: 6-29). SSO, SSI, and SSOPI rates were 39 (52%), 12 (16%), and 32 (42%), respectively. Conclusions: Managing VH remains a surgical challenge, emphasizing the importance of achieving effective abdominal closure for both functional and cosmetic outcomes. MCT presents a relatively simple approach compared to techniques like transversus abdominis release (TAR) and anterior component separation (ACS), with acceptable rates of SSO, SSOPI, SSI, and recurrence.

The Clinic's first experience in treating large and giant postoperative ventral hernia using the posterior separation technique Transversus Abdominis Release

The Clinic's first experience in treating large and giant postoperative ventral hernia using the posterior separation technique Transversus Abdominis Release

Posterior components separation with transversus abdominis release and sublay mesh reinforcement in large ventral hernia repair

AbstractAimVentral abdominal hernia is a prevalent condition among surgical patients. Large ventral hernias with defects &gt;10 cm that cannot be closed primarily, often with loss of domain requiring abdominal wall reconstruction, pose a surgical challenge. Our study aimed to evaluate the outcomes of posterior components separation (PCS) with transversus abdominis release (TAR) and sublay mesh reinforcement in large ventral hernia repair, particularly in terms of surgical site occurrences (SSOs) and hernia recurrence.Patients and MethodsOur study included 40 adult patients presented to Tanta University Hospitals with a large ventral hernia (defect width ≥10 cm) from December 2021 to January 2023. All patients were submitted to PCS with TAR and sublay mesh reinforcement.ResultsThe mean age of the study population was 47.32 (standard deviation [SD] 9.31) years (range 36–65 years) with a mean body mass index of 33.55 (SD 3.42) kg/m2 (range 28.35–38.72 kg/m2). The major risk factors were obesity (95.00%), smoking (45.00%), and multiparity (45.00%). Midline incisional hernia was the most common type in 28 patients (70.00%). Thirty‐four patients (85%) achieved successful midline closure, while six patients required additional anterior components separation technique to achieve tensionless midline closure and an onlay mesh for functional reconstruction. Post‐operative SSOs occurred in 12 patients (30.00%), with subcutaneous seroma in 8 patients (20.00%) and wound dehiscence and necrosis in 4 patients (10.00%). Two patients (5.00%) experienced recurrence after a mean follow‐up period of 19.25 (SD 3.52) months.ConclusionsPCS with TAR and sublay mesh reinforcement is a reliable and durable technique for complex ventral hernia repair with low morbidity and recurrence rates. However, long‐term clinical outcomes with more cases are required to properly evaluate this technique.

Feasibility of Posterior Component Separation with Transversus Abdominis release in complex ventral hernias : outcomes and experience at a single centre

Feasibility of Posterior Component Separation with Transversus Abdominis release in complex ventral hernias : outcomes and experience at a single centre

Limitations of Transversus Abdominis Release (TAR)-Additional Bridging of the Posterior Layer And/Or Anterior Fascia Is the Preferred Solution in Our Clinical Routine If Primary Closure is Not Possible.

Background: By separating the abdominal wall, transversus abdominis release (TAR) permits reconstruction of the abdominal wall and the placement of large mesh for many types of hernias. However, in borderline cases, the mobility of the layers is inadequate, and additional bridging techniques may be required for tension-free closure. We now present our own data in this regard. Patients and Methods: In 2023, we performed transversus abdominis release on 50 patients as part of hernia repair. The procedures were carried out using open (n = 25), robotic (n = 24), and laparoscopic (n = 1) techniques. The hernia sac was always integrated into the anterior suture and, in the case of medial hernias, was used for linea alba reconstruction. Results: For medial hernias, open TAR was performed in 22 cases. Additional posterior bridging was performed in 7 of these cases. The ratio of mesh size in the TAR plane to the defect area (median in cm) was 1200cm2/177cm2 = 6.8 in patients without bridging, and 1750cm2/452cm2 = 3.8 in those with bridging. The duration of surgery (median in min) was 139 and 222min and the hospital stay was 6 and 10 days, respectively. Robotic TAR was performed predominantly for lateral and parastomal hernias. These procedures took a median of 143 and 242min, and the hospital stay was 2 and 3 days, respectively. For robotic repair, posterior bridging was performed in 3 cases. Discussion: Using the TAR technique, even complex hernias can be safely repaired. Additional posterior bridging provides a reliable separation of the posterior plane from the intestines. Therefore, the hernia sac is always available for anterior reconstruction of the linea alba. The technique can be implemented as an open or minimally invasive procedure.

PARASTOMAL HERNIA REPAIR IN BRICKER TYPE URINARY DIVERSION USING THE MODIFIED PAULI TECHNIQUE: A CASE REPORT

Abstract Introduction The incidence of parastomal hernia (PH) associated with Bricker ileal urinary diversion is approximately 20%. Surgery becomes necessary in the presence of symptoms or development of complications. Clinical case A 77-year-old woman with a Bricker urinary diversion following radical cystectomy presented to the emergency department with 72 hours of evolving obstructive symptoms, coupled with a large PH featuring incarcerated bowel. A CT scan confirmed complete intestinal obstruction. Urgent surgery was conducted, revealing ileum incarceration without perforations. Reduction of the intestinal content was performed, restoring viability. Transversus abdominis release (TAR) around the stoma was executed, followed by the placement of a retromuscular progrip mesh using the Pauli technique. The patient was discharged after 8 days without complications. Discussion The surgical treatment of PH remains controversial, lacking a consensus as the most effective technique. We opted for modified Pauli technique, involving retromuscular dissection, subsequent components separation via TAR and mesh repair according to the Keyhole technique. This combination leverages the advantages of each of procedures to reduce the recurrence risk: retromuscular mesh placement physiologically pushing the wall, utilization of wider prostheses reinforcing a larger surface area, complete mesh contact with the wall facilitating integration around the defect, and direct stoma exit without the need for repositioning. Conclusions The modified Pauli technique with Keyhole mesh placement, while demanding, can provide advantages in emergency surgery without causing significant postoperative complications.

STAGED, LAPAROSCOPIC HYBRID EPAULI REPAIR FOR LARGE PARASTOMAL HERNIA – CASE REPORT

Abstract Background Managing large parastomal hernias poses significant challenges due to their high recurrence rates and the elevated risk for peri- and post-operative complications. Method Case report of a successful repair of a large parastomal hernia using a staged minimally invasive, hybrid approach. Results The patient underwent uncomplicated laparoscopic total colectomy in 2016 for ulcerative colitis. Several years later, in 2020, the patient presented to our hospital with a large parastomal hernia with obesity as comorbidity. To address this complex hernia, the patient was referred to the obesity team and underwent laparoscopic gastric sleeve resection in autumn 2021. In 2022, the patient's BMI had decreased to below 30, prompting the decision to proceed with hernia surgery. In May 2022, we performed chemical component separation using 300 units of Botox. Four weeks later, laparoscopic hybrid Epauli repair was undertaken. The laparoscopic component involved reducing hernia contents, abdominal wall dissection with Transversus Abdominis Release (TAR), mesh placement, and closing the posterior layer. Open surgery was interspersed throughout the laparoscopic procedure and at its conclusion. This included temporary stoma closure and reduction, temporary stoma site closure, medial repositioning of the stoma through rectus, excess skin excision, and stoma re-suturing. The patient experienced an uncomplicated recovery. In January 2023, the patient underwent complete abdominoplasty. A one-year postoperative CT scan and clinical control demonstrated a satisfactory outcome. Conclusion For complex and large parastomal hernias, hybrid surgery, combining open and minimally invasive approaches, offers a valuable operative strategy for managing such large hernias.

Surgical anatomy of transversus abdominis muscle for transversus abdominis release.

Transversus abdominis release (TAR) is a myofascial release technique which helps in surgical repair of large ventral abdominal wall defects. In this procedure, the medial margin of muscular part of transversus abdominis (TA) is of great importance. Hence, the authors sought to describe the extent of medial margin of TA muscle. The surgical steps of TAR were performed in 10 formalin-fixed cadavers and distance between medial margin of TA muscle, lateral margin of rectus abdominis, to linea alba at five anatomical levels were documented respectively. The distance between the inferior epigastric vessels and the medial border of TA muscle was also noted. The TA muscle was within the posterior rectus sheath in all cadavers, at the xiphisternum (R, 61.6 mm; L, 58.9 mm), and at midway between xiphisternum and umbilicus (R, 25.4 mm; L, 27.1 mm). The TA muscle exited the posterior rectus sheath between this point and the umbilicus. The mean incongruity at the next three levels were -24.6 mm, -24.9 mm, and -22.9 mm respectively on the right and -21.4 mm, -19.9 mm, and -18.9 mm respectively on the left. The mean distance between the medial border of TA and inferior epigastric vessels was 18.9 mm on the right and 17.2 mm on the left. The muscular part of TA was incorporated within the posterior rectus sheath above the umbilicus, and it completely exited the rectus sheath at the umbilicus. This is contrary to the traditional understanding of posterior rectus sheath formation.

ROBOT-ASSISTED EXTRAPERITONEAL VENTRAL HERNIA REPAIR—EXPERIENCE FROM THE FIRST 160 CONSECUTIVE OPERATIONS WITH LATERAL eTEP AND eTAR TECHNIQUES

Abstract Background As in various other surgical domains, robotically assisted procedures have become integral in the management of ventral hernias in recent years. The employment of robotic technology enables the integration of minimally invasive techniques with retromuscular mesh placement. Beyond the conventional transabdominal approach, these surgical interventions can alternatively be executed in a total extraperitoneal fashion. The objective of this study is to demonstrate that robotic total extraperitoneal management of abdominal wall hernias is safe and efficient. Method A retrospective analysis encompassing all patients who underwent robotic surgery for ventral hernia repair utilizing the extraperitoneal eTEP technique with a lateral approach was conducted. The study period spanned from December 2019 to December 2023. Results Over the study period, a total of 160 patients underwent surgical intervention utilizing the lateral robotic eTEP technique. Among these cases, 43 patients required a lateral extension of retro-rectal dissection through extraperitoneal transversus abdominis release (eTAR) due to either the hernia size or lateral hernia localization. In every instance, an uncoated synthetic mesh was positioned in the retromuscular location, accompanied by complete fascial closure. The median hernia defect area was 25 cm² (2.25–375 cm²). The median mesh size was 540 cm² (225–1350 cm²). The median mesh defect ratio (MDR) was 21 (2.3–150). Two conversions (1.72%) were necessary. One intraoperative and seven postoperative complications were encountered (5%) out of which two required reoperations (1.72%). Conclusion The robotic extraperitoneal eTEP technique enables a retromuscular mesh placement in a minimally invasive approach. With the possibility of combination with a transversus abdominis release, even complex findings can be treated using this technique.

PATIENT CASE STUDY: REBUILDING A PATIENT’S LIFE NOT JUST THEIR ABDOMINAL WALL – EXPERIENCE FROM A TERTIARY HERNIA CENTRE ON THE IMPACT OF ABDOMINAL WALL RECONSTRUCTION ON QUALITY OF LIFE

Abstract Introduction Abdominal wall reconstruction is a transformative intervention, significantly improving the quality of life for individuals with complex defects. This paper focuses on sharing a patient's experience post-surgery. Case Presentation The patient presented with a complex incisional hernia following a laparotomy, Hartmann’s procedure and splenectomy for perforated diverticular disease. Their CT scan showed a 16.5 × 17.5 cm defect, with a separate component involving their colostomy and lateral displacement of their muscle complexes. The hernia significantly impacted the patient's quality of life, manifesting as daily moderate pain that hindered routine activities. They required daily dressings and antibiotics due to skin changes over the hernia. Furthermore, dissatisfaction with the cosmetic appearance of the hernia contributed to the overall burden on the patient. Management and Outcomes The patient underwent pre-operative botulinum toxin injections six weeks prior to their abdominal wall reconstruction. They received 200 units divided equally between internal and external obliques. During their surgery they required a left sided transversus abdominus release and an &amp;gt;5cm mesh overlap was achieved in all directions. A post-operative CT scan conducted ten days after the surgery revealed no complications. The patient's recovery progressed well, leading to their discharge 12 days post-surgery. Discussion The patient was reviewed nine months post-surgery. Expressing high satisfaction with the surgical outcome, they conveyed a profound positive impact on their quality of life. The patient's newfound confidence in the improved cosmesis of their hernia was evident. Overall, the surgery proved transformative, liberating the patient from the burdens of frequent medical appointments and instilling a renewed sense of self-assurance.

Robotic transversus abdominis release using HUGO RAS system: our initial experience.

Transversus abdominis release (TAR) is an effective technique for treating large midline and off-midline hernias. Recent studies have demonstrated that robotic TAR (rTAR) is technically feasible and associated with improved outcomes compared to open surgery. There is no published experience to date describing abdominal wall reconstruction using the novel robotic platform HUGO RAS System (Medtronic®). All consecutive patients who underwent a rTAR in our institution were included. Three of the four arm carts of the HUGO RAS System were used at any given time. Each arm configuration was defined by our team in conjunction with Medtronic® personnel. rTAR was performed as previously described. Upon completion of the TAR on one side, a redocking process with different, mirrored arms angles was performed to continue with the contralateral TAR. Operative variables and early morbidity were recorded. Ten patients were included in this study. The median BMI was 31 (21-40.6) kg/m2. The median height was 1.6m (1.5-1.89m). A trend of decreased operative time, console time, and redocking time was seen in these consecutive cases. No intraoperative events nor postoperative morbidity was reported. The median length of stay was 3 (1-6) days. Robotic TAR utilizing the HUGO RAS system is a feasible and safe procedure. The adoption of this procedure on this novel platform for the treatment of complex abdominal wall hernias has been successful for our team.

Outcomes of posterior sheath supplementation with Vicryl mesh in TAR-a single-center study.

In the Transversus Abdominis Release (TAR) procedure, ideally, the posterior sheath is completely reapproximated to establish an interface isolating the polypropylene mesh from visceral contents. When primary closure of the posterior sheath is unachievable, Vicryl mesh is commonly used to supplement the posterior sheath closure and an uncoated polypropylene mesh is placed superficial to the Vicryl mesh. The long-term implications of utilizing Vicryl mesh as an antiadhesive barrier are poorly understood. In this study, we aimed to assess our outcomes when utilizing Vicryl mesh to supplement the posterior sheath defects when placed underneath polypropylene mesh in patients undergoing posterior component separation. Adult patients who underwent VHR with concurrent TAR procedure with a permanent synthetic mesh and posterior sheath supplementation with Vicryl mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and December 2022 were queried retrospectively from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term mesh-related complications, and pragmatic hernia recurrence. 53 patients who underwent TAR procedure with posterior sheath supplementation using Vicryl mesh and had a minimum 12-month follow-up were identified. Of the53 patients, 94.3% presented with recurrent hernias, 73.6% had a midline hernia, 7.5% had a flank hernia, and 18.9% had concurrent parastomal hernia. The mean hernia width was 24.9 cm (± 8.8 cm). No Vicryl mesh-related operative complications were identified in our study, with no instances of mesh erosion, fistulas, or interventions for small bowel obstruction. Skin necrosis requiring reoperations was observed in three patients (5.7%), leading to permanent mesh excision in two cases (3.8%) without intraabdominal visceral involvement. Throughout the 12-month follow-up, 23 incidences (43.4%) of surgical site occurrences (SSOs) and surgical site occurrences requiring procedural intervention (SSOPI) were documented. Our findings suggest that posterior sheath supplementation with Vicryl mesh is a feasible approach to achieve posterior sheath closure in challenging abdominal wall reconstruction cases. Given the absence of notable mesh-related complications and a similar hernia recurrence rate to cases without posterior sheath supplementation, Vicryl mesh can be used to safely achieve posterior sheath closure in complex reconstructions with insufficient native tissue.