VCOM Carolinas Research Day 2023

Clinical Studies

[Clinical Outcomes Following Robotic Abdominal Wall Reconstruction For Ventral Hernias Using Resorbable Biosynthetic Mesh Alexandra C. Skoczek, MPH, OMS-III 1 , Patrick W. Ruane, OMS-III 2 , Dennis L. Fernandez, M.D 3 Edward Via College of Osteopathic Medicine – Auburn 1 , Edward Via College of Osteopathic Medicine – Carolinas 2 , Crestwood Medical Center 3

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• Currently, the open approach, and the minimally invasive laparoscopic approach are the mainstays for ventral hernia repair in the United States. • These current techniques while initially effective have been shown to have high rates of surgical site occurrences (SSO), recurrence rates, and prolonged hospital length of stays (LOS, defined in the literature as >4 days postoperatively). 1 • Modifiable comorbidities (MCMs) such as diabetes, smoking, and obesity have been shown to further increase the risk of postoperative complications. 2 • Due to the postoperative risk surgeons are hesitant to perform hernia repair on patients with MCMs until they have been corrected. • Robotic hernia repairs have been shown to have better postoperative outcomes including recurrence at 3-year follow up. 3-5 • No studies have been conducted evaluating MCMs effects on postoperative complications when a robotic technique has been used. • We hypothesized that there would be no difference in postoperative outcomes (SSO, recurrence rate, and prolonged LOS) in patients with and without MCMs following robotic transversus abdominis release (TAR) with resorbable biosynthetic mesh underlay for primary ventral hernia repair. –

δ ͸Ͳ Univariate Analysis

Abstract #CLIN-7

• Patients with 2+ MCM have increased odds of SSO within 60 days of robotic abdominal wall reconstruction for ventral hernia repair. • On the breakdown of comorbidities specifically a history of diabetes and obesity is associated with increased odds of SSO. • While a difference is seen in postoperative LOS and prolonged LOS > 4 days in patients who have 0, 1, or 2+ MCMs, having MCMs was not associated with increased odds of prolonged LOS > 4 days. • At 36-month follow up no difference in hernia recurrence was seen between patients with 0, 1, or 2+ MCMs, and MCMs were not associated with increased odds of hernia recurrence. • Overall recurrence rate was found to be 9.7% while patients with 0 MCMs had a recurrence rate of 2.7% and patients with 2+ MCMs had a recurrence rate of 11%. • Robotic transversus abdominis release (TAR) with resorbable biosynthetic mesh underlay for primary ventral hernia repair may be a successful approach to decrease the odds of postoperative complications in patients with MCMs, however, further studies will be needed to evaluate its effectiveness compared to other currently available approaches.

•

2+ MCM is associated with statistically significant increased odds of SSO • OR = 3.25 [1.12 – 9.74] • P value = 0.019 Of the 2+ MCM combinations diabetes + obesity is associated with a statistically significant increased odds of SSO • OR = 3.52 [1.03 – 10.68] • P value = 0.02

No MCM

1 MCM N = 193 3.1% (6) 1.0% (2)

2+ MCM N = 93 8.6% (8) 2.2% (2)

Combined N = 344 4.4% (15) 1.2% (4) 0.3% (1) 2.9% (10)

P value

N = 58

SSO

1.7% (1)

0.087

Seroma Cellulitis Abscess

0% (0)

0.6 0.2

1.7% (1)

0% (0)

0% (0)

0% (0)

2.1% (4)

6.5% (6)

0.05

•

Multivariable logistic regression Variable

P value

Odds ratio

CI 95%

1 MCM 2+ MCM No MCM

0.511 0.386

.016 - 1.99 .165 - 1.48 1.12 - 9.74

0.28 0.20

0.019

3.25

Univariate Analysis

Diabetes + Obesity

Obesity + Smoking

Diabetes + Obesity + Smoking

No Comorbidity Diabetes

Obesity N = 155 3.2% (5)

Combined N = 344 4.4% (15)

P value

N = 58 1.7% (1)

N = 20 5% (1)

N = 4 6 11% (5)

N = 32

N = 11 18% (2)

SSO within 60 days

3.1% (1)

0.11

Multivariable logistic regression SSO

P value

Variable

Odds Ratio 0.386

1.03 - 10.68 .052 - 7.16 .181 - 1.77 95% CI .016 - 1.99

No Comorbidity

0.31 0.81 0.39 0.02 0.71

Diabetes Obesity

3.54 0.77 1.31 0.61 5.68

Diabetes + Obesity Obesity + Smoking

.031 - 4.1

Diabetes + Obesity + Smoking

.733 - 25.74

0.087

ȋ ε Ͷ Ȍ Univariate Analysis

Preoperative

Postoperative

1. 3, 8mm, ports are placed on the left side (subcostal, left lateral, and left lower quadrant) 2. Neurovascular TAP block administered 3. Lysis of abdominal adhesions and reduction of hernia contents 4. Right rectus flap created and transversus abdominis muscle released through fascial dissection 5. Ports are placed on the right side 6. Mesh size is estimated externally, inserted through the right-sided port, and secured 7. Robot is undocked and moved to the right side for the creation of the left rectus flap 8. Anterior fascial defect is closed 9. Mesh is secured under the rectus abdominis 10. Posterior fascial defect is closed

• A significant difference in LOS and prolonged LOS >4 days was seen between MCM groups • However , none of the groups or individual MCM showed increased odds of prolonged LOS > 4 days

No MCM

1 MCM N = 193

2+ MCM N = 93

Combined N = 344 1.54 ± 1.85 4.9% (17)

P value

N = 58

0.027 0.014

LOS (mean ± SD)

1.74 ± 1.65

1.31 ± 1.20

1.91 ± 1.85

LOS > 4 days

8.6% (5)

2.1% (4)

8.6% (8)

Multivariable logistic regression Variable

P value

Odds ratio

CI 95%

2+ MCM 1 MCM No MCM

2.53 3.43 0.23 2.18

.66 - 6.24 .062 - .68 .91 - 6.9 1.08 - 15.8

0.156 0.006 0.057 0.036

Hypertension

Preoperative

Postoperative

Univariate Analysis

No Comorbidity Diabetes

Obesity N = 155

Diabetes + Smoking Diabetes + Obesity

Combined N = 344 1.54 ± 1.50 4.9% (17)

P value

N = 58

N = 20

N = 4

N = 4 6

0.034 0.005

LOS (mean ± SD)

1.74 ± 1.65

1.70 ± 1.45

1.26 ± 1.18

3.50 ± 2.38

2.26 ± 2.21

LOS >4 days

8.6% (5)

5% (1)

1.9% (3)

25% (1)

15% (7)

Multivariable logistic regression LOS >4 days

P value

Variable

Odds Ratio 2.18 1.14 0.257

95% CI .66 - 6.24

No Comorbidity

0.156

Diabetes Obesity

.24 - 66.12 1.75 - 14.43 .0456 - 6.14 .056 - .817

0.99 0.02

Diabetes + Smoking Diabetes + Obesity

7.22 5.16

0.197

0.0006

͵͸Ǧ Univariate Analysis

• 344 patients met the inclusion criteria for SSO < 60 days analysis and prolonged LOS > 4 days analysis • Retrospective review of medical records for patients who underwent robotic abdominal wall reconstruction for ventral hernia repair between 2015 and 2022 performed by a single surgeon. • Analysis included univariate analysis comparing all 3 major groups, a multivariable logistic regression model made for the different groups, and the two combined groups were then divided into all possible scenarios and analyzed.

Perioperative Intra-Abdominal TAR/Anterior Fascial Closure

• No significant difference in hernia recurrence was observed between the different MCM groups • No group or individual MCM showed significantly increased odds of hernia recurrence

No MCM

1 MCM N = 84

2+ MCM N = 54 11% (6) 10 ± 36

Combined N = 175 9.7% (17)

P value

N = 37

Recurrence

2.7% (1)

12% (10) 11 ± 39

0.265 0.283

Weeks between surgery and recurrence (mean ± SD) 4 ± 21

9 ± 35

Multivariable logistic regression Variable

P value

Odds ratio

CI 95%

2+ MCM 1 MCM No MCM

0.241

.0097 - 1.25

0.105 0.350

1.26 1.61

.58 - 4.71 .41 - 3.57

1 MCM

No MCM

2 + MCM

0.68

• N = 93 • Age (median) = 57 • Hernia diameter, cm (mean ± SD) = 13.7 ± 5.8 • BMI (mean ± SD) = 38 ± 7

• N = 193 • Age (median) = 58 • Hernia diameter, cm (mean ± SD) = 12.4 ± 5.0 • BMI (mean ± SD) = 35 ± 7

• N = 58 • Age (median) = 60 • Hernia diameter, cm (mean ± SD) = 11.8 ± 4.5 • BMI (mean ± SD) = 26 ± 3

Univariate Analysis

Thank you to Crestwood Medical Center and the private practice of Dr. Dennis Fernandez for allowing this study to take place. Additional thanks to Dr. David Redden for reviewing and providing advice on statistical analysis. This study was reviewed and approved by the Edward Via College of Osteopathic Medicine IRB (#2022-079) on 09/27/2022.

Diabetes + Obesity

Obesity + Smoking N = 19 16% (3) 20 ± 55

No Comorbidity

Diabetes

Obesity N = 68 12% (8) 12 ± 43

Smoking

Combined N = 175 9.7% (17)

P value

N = 37

N = 11

N = 5

N = 28 11% (3) 5 ± 19

Recurrence

2.7% (1)

9.1% (1)

20% (1) 5 ± 11

0.50

• 175 patients met the inclusion criteria for hernia recurrence at 36-months analysis No MCM • N = 37 • Age (median) = 61 • Hernia diameter, cm (mean ± SD) = 10.7 ± 3.7 • BMI (mean ± SD) = 26 ± 3 1 MCM • N = 84 • Age (median) = 58 • Hernia diameter, cm (mean ± SD) = 12.5 ± 5.2 • BMI (mean ± SD) = 35 ± 7 2 + MCM • N = 54 • Age (median) = 55 • Hernia diameter, cm (mean ± SD) = 14.9 ± 6.0 • BMI (mean ± SD) = 39 ± 7

Weeks between surgery and recurrence (mean ± SD) Multivariable logistic regression recurrence at 36-months

4 ± 21

5 ± 16

9 ± 35

0.727

P value

Variable

Odds Ratio

95% CI

No Comorbidity

0.241

.0097 - 1.25 .037 - 6.08 .511 - 4.06 .092 - 20.40 .246 - 4.01 .398 - 6.95

0.105 0.976 0.477 0.479 0.813 0.369

Diabetes Obesity Smoking

1.03 1.45 2.62 1.18 1.96

Diabetes + Obesity Obesity + Smoking

48

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