Clinical outcomes and cost of robotic ventral hernia repair: systematic review.
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SUBMITTER: Ye L
PROVIDER: S-EPMC8599882 | biostudies-literature | 2021 Nov
REPOSITORIES: biostudies-literature
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Clinical outcomes and cost of robotic ventral hernia repair: systematic review.
Ye Linda L Childers Christopher P CP de Virgilio Michael M Shenoy Rivfka R Mederos Michael A MA Mak Selene S SS Begashaw Meron M MM Booth Marika S MS Shekelle Paul G PG Wilson Mark M Gunnar William W Girgis Mark D MD Maggard-Gibbons Melinda M
BJS open 20211101 6
<h4>Background</h4>Robotic ventral hernia repair (VHR) has seen rapid adoption, but with limited data assessing clinical outcome or cost. This systematic review compared robotic VHR with laparoscopic and open approaches.<h4>Methods</h4>This systematic review was undertaken in accordance with PRISMA guidelines. PubMed, MEDLINE, Embase, and Cochrane databases were searched for articles with terms relating to 'robot-assisted', 'cost effectiveness', and 'ventral hernia' or 'incisional hernia' from 1 ...[more]
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Project description:ImportanceAlthough the use of robotic-assisted ventral hernia repairs has increased significantly over the last decade, the experience surgeons need to achieve comparable outcomes with more established laparoscopic and open approaches has not been well characterized.ObjectiveTo estimate the learning curves for robotic-assisted ventral (incisional and umbilical) hernia repair.Design, setting, and participantsThis retrospective cohort study included Medicare fee-for-service patients (≥18 years) enrolled in Medicare Part A and Part B with no managed care undergoing ventral hernia repairs between 2010 and 2020. Multivariate logistic regression was used to estimate reoperation rates for hernia recurrence, adjusting for patient demographics, comorbidities, mesh placement, and hospital characteristics. Analyses were conducted from October 2023 to July 2024.ExposureIncremental robotic-assisted hernia repair volume.Main outcome and measureReoperation for hernia recurrence within 7 years of index hernia repair.ResultsThis study comprised 160 379 Medicare patients (mean [SD] age, 69 [11] years), of whom 93 272 (58.2%) were female, 13 799 (8.6%) were Black, 3124 (2.0%) were Hispanic, and 138 311 (86.2%) were White. Among these patients, 12 609 (7.9%) underwent robotic-assisted hernia repairs, 32 337 (20.2%) laparoscopic repairs, and 115 433 (71.9%) open repairs. This study also included 23 580 surgeons, with 5074 performing robotic-assisted hernia repairs. The national reoperation rates for hernia recurrence after laparoscopic and open repairs were 12.5% (95% CI, 12.06%-12.94%) and 12.9% (95% CI, 12.70%-13.15%), respectively. Reoperation rates decreased as the number of robotic-assisted cases increased, from 14.2% (95% CI, 13.34%-14.97%) at 10 cases to 7.6% (95% CI, 6.75-8.37) at 50 cases. Surgeons needed at least 19 (95% CI, 16-22) robotic-assisted hernia repairs or 16 (95% CI, 13-19) repairs to achieve outcomes equivalent to those of laparoscopic and open procedures. Few surgeons (285 surgeons [5.7%]) performed enough robotic-assisted ventral hernia repairs to achieve necessary volume nationally to overcome the learning curve.Conclusions and relevanceIn this cohort study of 23 580 surgeons who performed ventral hernia repairs between 2010 and 2020, increasing experience with robotic-assisted hernia repairs was associated with improved long-term reoperation rates for hernia recurrence. However, the majority of surgeons did not perform enough cases to reach reoperation rates equivalent to more established laparoscopic and open approaches.
| S-EPMC11615711 | biostudies-literature
Project description:ImportanceDespite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.ObjectiveTo determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain.Design, setting, and participantsA registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.InterventionsPatients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh.Main outcomes and measuresThe trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost.ResultsSeventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).Conclusions and relevanceLaparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.Trial registrationClinicalTrials.gov Identifier: NCT03283982.
| S-EPMC7578919 | biostudies-literature
Project description:Within the past decade, poly-4-hydroxybutyrate (P4HB) biosynthetic mesh has been introduced as a potential alternative to traditional biologic and synthetic mesh in ventral hernia repair (VHR). The aim of this study was to systematically assess clinical outcomes with the P4HB in VHR.MethodsA literature search identified all articles published in 2000 involving the use of P4HB in VHR. Descriptive statistics were used to synthesize collective data points, including postoperative outcomes. A pooled analysis of postoperative outcomes was performed using chi-square test and Fisher exact test.ResultsAcross 7 studies, the P4HB was used in 453 patients. The mean rate of surgical site infection (SSI) was 6.8% (31/453), reoperation 10.7% (30/281), and recurrence 9.1% (41/453). At an average follow-up of 26.8 months, the incidence of recurrence was 10.4% (28/270). Onlay was significantly associated with increased recurrence (14.2% versus 4.4%, P = 0.001). Among sublay placements, there was no difference in recurrence in clean (Center for Disease Control [CDC] 1) or contaminated (CDC >1) wounds (2.7% versus 6.1%, P = 0.585), but contaminated wounds were associated with increased SSI (2.7% versus 15.2%, P = 0.028). Ventral Hernia Working Group grade 2 and 3 did not have different incidences of recurrence (8.0% versus 5.1%, P = 0.526) nor SSI (5.1% versus 14.6%, P = 0.265).ConclusionsOverall, clinical outcomes of the P4HB mesh in VHR are acceptable. The P4HB mesh serves as a reliable alternative to traditional synthetic and biologic mesh across a range of defect characteristics and patient health conditions. Further research is needed to better understand the conditions in which it may provide a clinical benefit over traditional mesh types.
| S-EPMC7787297 | biostudies-literature
Project description:ObjectiveTo determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair.DesignPragmatic, blinded randomized controlled trial.SettingMultidisciplinary hernia clinics in Houston, USA.Participants124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019.InterventionsRobotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59).Main outcome measuresThe primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat.ResultsPatients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair.ConclusionThis study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs.Trial registrationClinicaltrials.gov NCT03490266.
| S-EPMC7359869 | biostudies-literature
Project description:ObjectiveReport the 2-year outcomes of a multicenter randomized controlled trial comparing robotic versus laparoscopic intraperitoneal onlay mesh ventral hernia repair.BackgroundVentral hernia repair is one of the most common operations performed by general surgeons. To our knowledge, no studies have been published to date comparing long-term outcomes of laparoscopic versus robotic ventral hernia repair.MethodsThe trial was registered at clinicaltrials.gov (NCT03490266). Clinical outcomes included surgical site infection, surgical site occurrence, hernia occurrence, readmission, reoperation, and mortality.ResultsA total of 175 consecutive patients were approached that were deemed eligible for elective minimally invasive ventral hernia repair. In all, 124 were randomized and 101 completed follow-up at 2 years. Two-year follow-up was completed in 54 patients (83%) in the robotic arm and 47 patients (80%) in the laparoscopic arm. No differences were seen in surgical site infection or surgical site occurrence. Hernia recurrence occurred in 2 patients (4%) receiving robotic repair versus in 6 patients (13%) receiving laparoscopic repair (relative risk: 0.3, 95% CI: 0.06-1.39; P =0.12). No patients (0%) required reoperation in the robotic arm whereas 5 patients (11%) underwent reoperation in the laparoscopic arm ( P =0.019, relative risk not calculatable due to null outcome).ConclusionsRobotic ventral hernia repair demonstrated at least similar if not improved outcomes at 2 years compared with laparoscopy. There is potential benefit with robotic repair; however, additional multi-center trials and longer follow-up are needed to validate the hypothesis-generating findings of this study.
| S-EPMC10966958 | biostudies-literature
Project description:Background:The objective of the present study is to compare the outcomes open PVHR and robotic PVHR. Methods/Design:The present study will be a randomized single-blinded controlled trial with intention-to-treat analysis comparing robotic PVHR to open PVHR in adult patients undergoing elective PVHR with a defect ranging between 1-5 cm. Patient refusing to participate, not able to give informed consent, with history of intra-abdominal surgery contraindicating a robotic surgical approach will be excluded. The intervention will consist in laparoscopic robotically assisted trans-abdominal pre-peritoneal epigastric or umbilical PVHR with closure of fascial defect and non-adsorbable mesh reinforcement. The control will be open pre-peritoneal epigastric or umbilical hernia repair with closure of fascial defect and non-absorbable mesh reinforcement. The primary outcome will be the incidence of wound-related complication within 1 month. The secondary outcomes will be esthetic satisfaction, pain, pain-killers consumption, general complications, costs, operative time and early hernia recurrence. Discussion:Open PVHR is potentially associated to more wound-related complications, but has the advantages of cost-effectiveness, short operative time and totally extra-peritoneal repair. Laparoscopic PVHR has lower wound-related complications but implies placing the mesh in intra-peritoneal position, requires advanced laparoscopic skills, usually does not allow the closure of the defect, and can lead to excessive pain and pain-killers consumption. Robotic PVHR uses the same laparoscopic access as laparoscopic PVHR, but thanks to the extended range of motion given by the robotic system, allows defect closure, pre-peritoneal placement of the mesh and requires less technical skills.In the present randomized controlled trial, we expect to show that robotic PVHR leads to better wound-related outcomes than open PVHR. Trial registration:The present randomized controlled trial was registered into clinicaltrials.gov under registration number NCT04171921.
| S-EPMC7186553 | biostudies-literature
Project description:BackgroundIn both clinical practice and residency training, the use of robotic platforms in surgery is becoming more common. The aim of this study was to perform a systematic review of the perioperative outcomes of robotic and laparoscopic paraesophageal hernia (PEH) repair.MethodsThe PRISMA statement guidelines were used to perform this systematic review. We conducted a database search which included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. There were 384 articles discovered in the initial search using various keywords. From those 384 articles, after duplicates were removed and publications were eliminated based on eligibility criteria, 7 publications were then chosen for analysis. Risk of bias was assessed using Cochrane Risk of Bias Assessment Tool. Narrative synthesis of results has been provided.ResultsWhen compared to standard laparoscopic approaches, robotic surgery for large PEHs may offer benefits in terms of decreased conversion rate and shorter hospital stay. Some studies found a decrease in need for esophageal lengthening procedures and fewer long-term recurrences. The perioperative complication rate is similar between the two techniques in most studies; however, one large study of nearly 170,000 patients in the early years of robotics adoption demonstrated a higher rate of esophageal perforation and respiratory failure in the robotic group (2.2% increase in absolute risk). Cost is another disadvantage of robotic repair when compared to laparoscopic repair. Our study is limited by the non-randomized and retrospective nature of the studies.ConclusionsMore studies into recurrence rates and long-term complications are needed to determine the efficacy of robotic versus laparoscopic PEHs repair.
| S-EPMC10089873 | biostudies-literature
Project description:BackgroundEndoscopic onlay repair (ENDOR) approach is gaining traction as a promising technique for the treatment of diastasis recti and associated ventral hernia. However, comprehensive evidence regarding its perioperative and short-term outcomes remains scarce. The objective of this meta-analysis is to provide a comprehensive summary of the existing evidence concerning perioperative and short-term postoperative outcomes.MethodsA systematic literature review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL until August 1st, 2024. Articles reporting outcomes of ENDOR in adult population diagnosed with diastasis recti associated or not with primary or incisional ventral hernia were included. Primary outcomes were evaluated based on safety and short-term measures, including intraoperative and short-term postoperative characteristics. A fixed effects model was used for meta-analysis. The methodological quality of the studies was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria.ResultsA total of 12 studies (480 patients) were identified. Minimally invasive ENDOR resulted in an intraoperative complications and conversion rate of 1.0% [95% CI 0.0-2.0%]. The rate of seroma was 25% [95% CI 12.0-39.0%], the one of surgical site infection was 1% [95% CI 0.0-2.0%] and the rate of hematoma was 2% [95% CI 1.0-3.0%]. After a median follow-up of 16 months (1.8-39), the rate of recurrence was 2% [95% CI 0.0-3.0%].ConclusionsThe minimally invasive ENDOR approach stands out as a safe and effective method for diastasis recti and associated ventral hernia repair in selected patients, exhibiting low rates of intraoperative complications and yielding favorable outcomes. Prospero registry Registration number: CRD42024573235.
| S-EPMC11870909 | biostudies-literature
Project description:ImportanceAlthough multiple versions of polypropylene mesh devices are currently available on the market for hernia repair, few comparisons exist to guide surgeons as to which device may be preferable for certain indications. Mesh density is believed to impact patient outcomes, including rates of chronic pain and perception of mesh in the abdominal wall.ObjectiveTo examine whether medium-weight polypropylene is associated with less pain at 1 year compared with heavy-weight mesh.Design, setting, and participantsThis multicenter randomized clinical trial was performed from March 14, 2017, to April 17, 2019, with 1-year follow-up. Patients undergoing clean, open ventral hernia repairs with a width 20 cm or less were studied. Patients were blinded to the intervention.InterventionsPatients were randomized to receive medium-weight or heavy-weight polypropylene mesh during open ventral hernia repair.Main outcomes and measuresThe primary outcome was pain measured with the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Short Form 3a. Secondary outcomes included quality of life and pain measured at 30 days, quality of life measured at 1 year, 30-day postoperative morbidity, and 1-year hernia recurrence.ResultsA total of 350 patients participated in the study, with 173 randomized to receive heavy-weight polypropylene mesh (84 [48.6%] female; mean [SD] age, 59.2 [11.4] years) and 177 randomized to receive medium-weight polypropylene mesh (91 [51.4%] female; mean [SD] age, 59.3 [11.4] years). No significant differences were found in demographic characteristics (mean [SD] body mass index of 32.0 [5.4] in both groups [calculated as weight in kilograms divided by height in meters squared] and American Society of Anesthesiologists classes of 2-4 in both groups), comorbidities (122 [70.5%] vs 93 [52.5%] with hypertension, 44 [25.4%] vs 43 [24.3%] with diabetes, 17 [9.8%] vs 12 [6.8%] with chronic obstructive pulmonary disease), or operative characteristics (modified hernia grade of 2 in 130 [75.1] vs 140 [79.1] in the heavy-weight vs medium-weight mesh groups). Pain scores for patients in the heavy-weight vs medium-weight mesh groups at 30 days (46.3 vs 46.3, P = .89) and 1 year (30.7 vs 30.7, P = .59) were identical. No significant differences in quality of life (median [interquartile range] hernia-specific quality of life score at 1 year of 90.0 [67.9-96.7] vs 86.7 [65.0-93.3]; median [interquartile range] hernia-specific quality of life score at 30 days, 45.0 [24.6-73.8] vs 43.3 [28.3-65.0]) were found for the heavy-weight mesh vs medium-weight mesh groups. Composite 1-year recurrence rates for patients in the heavy-weight vs medium-weight polypropylene groups were similar (8% vs 7%, P = .79).Conclusions and relevanceMedium-weight polypropylene did not demonstrate any patient-perceived or clinical benefit over heavy-weight polypropylene after open retromuscular ventral hernia repair. Long-term follow-up of these comparable groups will elucidate any potential differences in durability that have yet to be identified.Trial registrationClinicalTrials.gov Identifier: NCT03082391.
| S-EPMC8444061 | biostudies-literature
Project description:Background: The introduction of mesh for reinforcement of ventral hernia repair (VHR) led to a significant reduction in hernia recurrence rates. However, it remains controversial whether synthetic or biologic mesh leads to superior outcomes. Recently, hybrid mesh consisting of reinforced biosynthetic ovine rumen (RBOR) has been developed and aims to combine the advantages of biologic and synthetic mesh; however, outcomes after VHR with RBOR have not yet been compared with the standard of care. Methods: We performed a retrospective analysis on 109 patients, who underwent VHR with RBOR (n = 50) or synthetic polypropylene mesh (n = 59). Demographic characteristics, comorbidities, postoperative complications, and recurrence rates were analyzed and compared between the groups. Multivariate logistic regression models were fit to assess associations of mesh type with overall complications and surgical site occurrence (SSO). Results: Patients who underwent VHR with RBOR were older (mean age 63.7 versus 58.8 years, P = 0.02) and had a higher rate of renal disease (28.0 versus 10.2%, P = 0.01) compared with patients with synthetic mesh. Despite an unfavorable risk profile, patients with RBOR had lower rates of SSO (16.0 versus 30.5%, P = 0.12) and similar hernia recurrence rates (4.0 versus 6.78%, P = 0.68) compared with patients with synthetic mesh. The use of synthetic mesh was significantly associated with higher odds for overall complications (3.78, P < 0.05) and SSO (3.87, P < 0.05). Conclusion: Compared with synthetic polypropylene mesh, the use of RBOR for VHR mitigates SSO while maintaining low hernia recurrence rates at 30-month follow-up.
| S-EPMC9746774 | biostudies-literature