|Year : 2021 | Volume
| Issue : 1 | Page : 7-12
Robotic inguinal hernia repair in patients aged eighty and older
Omar Yusef Kudsi, Fahri Gokcal, Naseem Bou-Ayash
Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, MA, USA
|Date of Submission||17-Sep-2020|
|Date of Acceptance||30-Sep-2020|
|Date of Web Publication||22-Feb-2021|
Dr. Omar Yusef Kudsi
One Pearl Street, Brockton, MA 02301
Source of Support: None, Conflict of Interest: None
BACKGROUND: Minimally invasive techniques, such as robotic inguinal hernia repair (RIHR), have potential benefits for patients in various clinical scenarios. However, the value of RIHR in older age groups has not yet been established, as increased age may place patients at a higher risk of postoperative morbidity and mortality. The aim of the study is to evaluate the feasibility of RIHR in patients ≥80 years old.
MATERIALS AND METHODS: Among patients who underwent RIHR between February 2013 and August 2020, patients ≥80 years old were included. Preoperative, intraoperative, and postoperative variables were reviewed. Postoperative complications were assessed according to the Clavien–Dindo (CD) classification and the Comprehensive Complication Index (CCI®) scoring system. Univariate and multivariate analyses were used to identify the risk factors for patients with complications.
RESULTS: A total of 51 patients were included in the study. The average operative time was 58.7 min. The average length of stay was 0.5 days. Urinary retention and seroma were the commonly encountered complications (CD Grades 1 and 2). A procedural intervention and overnight intensive care unit follow-up were needed in two patients for each (CD Grade-3a and-4a). The maximum morbidity CCI score was 43.3. There was no hernia recurrence or reoperation during the mean follow-up period of 42 months. No statistically significant difference was found between patients with and without complications.
CONCLUSION: This is the first study to demonstrate the feasibility of RIHR in patients ≥ 80-year-old. Although advanced age is associated with increased comorbidities and physiological irregularities, RIHR may be performed with short operative time, length of hospital stay, and low rate of postoperative complications in these patients.
Keywords: Elderly, groin hernia, inguinal hernia, octogenarian, oldest old, robotics
|How to cite this article:|
Kudsi OY, Gokcal F, Bou-Ayash N. Robotic inguinal hernia repair in patients aged eighty and older. Int J Abdom Wall Hernia Surg 2021;4:7-12
| Introduction|| |
Inguinal hernia repair (IHR) is a common procedure in daily surgical practice. Several operative techniques have been described, with traditional techniques relying on a tissue-based or a tension-free repair using an open approach. Since the first attempt at laparoscopic inguinal hernia repair (LIHR) by Ger et al., several modifications of LIHR have been introduced. Recent advances in surgical technology have given rise to robotic inguinal hernia repair (RIHR) as an alternate approach to minimally invasive IHR.
Worldwide, the older adult population is at its largest in history. While watchful waiting for mildly symptomatic inguinal hernias may be an acceptable option for older patients, senior citizens now lead more active lifestyles and have desire for faster postoperative recovery and return to activities of daily living. Advanced age may be a substantial comorbidity among surgical candidates for IHR, with some studies showing a higher rate of perioperative complications in patients aged 80 and above undergoing endoscopic IHR., On the other hand, some studies comparing open and LIHR in patients age 80 and above support the safety and feasibility of LIHR in this patient population. Although it is reported that robotic ventral hernia repair (RVHR) could be performed with acceptable postoperative outcomes in octogenarians in a prior study, RIHR in the same age group has not been evaluated.
This study aims to report the postoperative outcomes after RIHR in patients aged 80 and above and to discuss the specific surgical considerations for this population.
| Materials and Methods|| |
Study data surrounding patients who underwent RIHR between February 2013 and August 2020 were collected and managed using the research electronic data capture tool. From this database, patients age 80 or above were included. Patients under the age of 80 and patients who underwent concomitant procedures were excluded. Informed consent was obtained from all study participants.
The variables included patient characteristics (age, sex, body mass index, comorbidities, and American Society Anesthesiology score), hernia characteristics (etiology, side, and hernia contents), operative variables (mesh type, mesh dimensions, console and skin-to-skin times, and estimated blood loss), intraoperative complications, conversion to an open or laparoscopic approach, and postoperative variables (postoperative pain scores, length of hospital stay [LOS], hospital readmission within 30-days after discharge, and complications).
Postoperative pain scores were documented by an anesthesiologist using a 0–10 numeric rating scale system (0: no pain and 10: the worst pain). The pain score was recorded just before the patient left the postanesthesia care unit (PACU). The total amount of narcotic-analgesic received while in the PACU was also calculated in terms of morphine milligram equivalents (MME). The LOS, in days, was defined as the difference in time between the date of the operation and the date of hospital discharge.
Postoperative complications were reviewed as documented in the surgeon's follow-up visit notes, as well as the medical records of the patients. All complications were categorized according to the Clavien–Dindo (CD) classification system. The Comprehensive Complication Index (CCI®, University of Zurich, Zurich, Switzerland) was used to assess the morbidity. The EuraHS Working Group recommendations for reporting outcome results in abdominal wall repair were followed.
Robotic transabdominal preperitoneal inguinal hernia repair
The patient was placed in the supine position, and a Foley catheter was inserted. Following appropriate preparation, a Veress needle was inserted into the left upper quadrant to insufflate the abdomen, and a total of three trocars were inserted 8 cm apart and 4 cm above the level of the umbilicus and off-midline. The patient-side cart of the da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, CA) was docked. Each procedure involved an average of three instruments, including a 0° scope. After docking, the inguinal hernia was identified, and peritoneal dissection was initiated 8–10 cm above the internal inguinal ring, starting at the median umbilical fold and proceeding laterally toward the anterior superior iliac spine. The dissection was extended inferiorly toward the deep inguinal ring, laterally toward the psoas muscle, and medially at least 2 cm between Cooper's ligament and the bladder to allow adequate mesh overlap in the space of Retzius. Inferior epigastric vessels were preserved, cord structures were separated, and the hernia contents were then reduced. The hernia sac was carefully dissected from its attachments to avoid injury to the structures in the triangle of doom. If present, lipomas were either reduced or excised. The recommendations of the International Hernia Collaboration's critical view of the myopectineal orifice (MPO) were followed. After evaluation of the MPO for any hidden hernias and visualization of all anatomical elements, a minimum mesh size of 15 cm × 10 cm was introduced to cover the MPO. The peritoneal flap was then closed using absorbable barbed suture. Any fascial incisions larger than 10 mm, if present, as well as skin incisions, were closed using absorbable sutures after the administration of local anesthetic (1% bupivacaine hydrochloride) at the trocar sites.
All statistical analyses were performed using the SPSS software Statistical Package for the Social Sciences for Windows (Version 22, IBM Corp., Armonk, N.Y., USA). Continuous variables were determined as normally or nonnormally distributed by using either Kolmogorov–Smirnov or Shapiro–Wilk tests. Categorical variables were presented in terms of frequency (n [%]), while continuous variables were reported as the mean ± the standard deviation for normal distributions or the median with interquartile range (IQR) for nonnormal distributions. Univariate analyses were also performed, comparing all variables and the presence of postoperative complications. Categorical variables were analyzed using the Pearson Chi-square or Fisher's exact tests. Continuous variables were analyzed using the two-tailed Student's t-test (for normal distributions) or Mann–Whitney U-test (for nonnormal distributions). P < 0.05 was considered statistically significant.
| Results|| |
From the initial cohort of 630 patients, 51 patients who underwent RIHR, whose ages ranged from 80 to 94 years, were identified. Patient demographics are presented in [Table 1]. Considering bilateral hernias, a total of 65 hernias were repaired. The majority of cases were lateral (indirect) hernias. In 17 (33.3%) patients, the hernia was incarcerated. Of these, 6 (11.8%) patients underwent emergent repair. Hernia characteristics are summarized in [Table 2].
Imbrication of the hernia sac was performed in seven (13.7%) patients with a direct hernia. Median mesh size was 15 cm × 10 cm, and polyester mesh was used in the majority of cases. There were no intraoperative complications, and none of the patients needed a suction drain. In one patient (2%) with a bilateral giant scrotal hernia (>30 cm scrotal diameter), the operation was completed with a combination of robotic and open approaches (hybrid). Operative variables are presented in [Table 3].
The median (IQR) pain score was 2 (0–4). During the PACU recovery period, 35.3% of patients did not require any pain medication. The median (IQR) MME was 5 (0–12.2), and the mean hospital LOS was 0.5 days (range: 8). The majority of patients were discharged on the same day of operation (74.5%). Three (5.9%) patients were readmitted to the hospital within 30-day postoperatively. One patient was readmitted for a seroma requiring procedural intervention. The other two complications necessitating readmission were a transient ischemic attack and vomiting.
The mean postoperative follow-up period was 42 (minimum–maximum = 6.7–71.3) months, and two (3.9%) patients were noted as lost-to-follow-up. Postoperative complications are presented in [Table 4]. The majority of postoperative complications were Grade-1, based on the CD classification. In two patients with a postoperative seroma, a procedural intervention was needed (CD Grade-3a) and two patients required overnight intensive care unit follow-up for hemodynamic support (CD Grade-4a). No chronic groin pain was reported, and there were no hernia recurrences within the study period.
A comparison between patients who experienced and who did not experience any postoperative complication was given in [Table 5]. Accordingly, none of the variables showed statistical significance. Furthermore, a regression model was fit using the variables that may be clinically relevant. Recurrent hernia and incarcerated hernia variables were used for the model, but neither showed statistical significance (P = 0.173, odds ratio [OR] =3, 95% confidence interval [CI] = 0.618–14.628; P = 0.275, OR = 2.1, 95% CI = 0.555–7.953, respectively).
| Discussion|| |
Increasing age predisposes patients to a variety of physiologic perturbances, among which are a decreased cardiorespiratory reserve and skin and soft-tissue changes. These become especially problematic when coupled with the higher rates of chronic disease and comorbidities in this patient population. Age 70 or older has been identified as an independent predictor of increased postoperative complications, in-hospital mortality, and LOS. The advent of minimally invasive surgery, although minimizes postoperative complications and pain after IHR compared to open repair, presents particular concerns in elderly individuals in terms of the hemodynamic effects of pneumoperitoneum, as well as increased operative times for select procedures. Despite this however, the benefits of laparoscopy seem to outweigh the risks in the elderly population for a variety of procedures. For endoscopic IHR in specific, an analysis of 24,571 patients from the Herniamed Registry found that notably increased rates of postoperative surgical and general complications were observed starting at the age of 80 years. However, a regression analysis found these results to be of multifactorial origin, emphasizing the need for individualized treatments for these patients.
A study by Hernandez-Rosa et al. comparing the outcomes for open and laparoscopic repair of inguinal hernias in patients over the age of 80 revealed that IHR could be performed as a safe alternative to open repair with comparable morbidity and mortality. They reported that operative times were not significantly different in the two groups (73.2 ± 3.4 min for open vs. 78.1 ± 5.7 min for laparoscopic). Similarly, Hope et al. compared open and LIHRs in the same population. While a total of 23 octogenarian patients underwent lap-IHR, 58 patients underwent open IHR. There was no significant difference in operative time for either approach; the mean operative time was 59.6 min in the open group and 62.8 min in the laparoscopic group. In our study, the mean operative time was 58.7 min (median = 50 min) across 51 cases.
Irrespective of age, postoperative pain scores were reported in favor of robotic TAPP when compared to laparoscopic total extra peritoneal, as reported by Aghayeva et al. In a prospective randomized trial comparing postoperative outcomes between laparoscopic and RIHR, the change between preoperative and postoperative pain scores was similar between the groups. Dallas et al. reviewed the records of 115 patients aged 80 years and above, who underwent either open or LIHR. The mean pain score was 2.1 in the laparoscopic group versus 3 for the open group, with no statistical significance. In our study, the median (IQR) score was 2 (0–4), reflecting that of the laparoscopic group in Dallas et al.'s study.
Patients who have chronic disease and multiple impairments are likely to have longer inpatient LOS. Although the vast majority of the patients have at least one chronic disease, the average hospital LOS was 0.5 days in the current study. Hernandez-Rosa et al. reported 0.6 days for their laparoscopic group and 0.5 days for the open group. In a previous study on octogenarian patients who underwent RVHR, a strong correlation was found between the length of the operation and the LOS. A similar correlation was not observed in the current study. Payiziwula et al. compared seven octogenarian patients who underwent emergent LIHR (without mesh) to 11 conventional open IHRs. The mean LOS of the laparoscopic group was shorter than that of the open group (6 days vs. 12 days, respectively). In the current study, all patients who underwent RIHR in an emergent setting (6 [11.8%] patients) stayed overnight in the hospital for an average LOS of 2.6 days. Two patients who underwent LIHR in the Payiziwula et al.'s study required intestinal resection due to irreversible ischemia. In contrast, intestinal resection was not required in the current study's emergent subgroup, and neither emergent repair nor an increased LOS was associated with the presence of any complications. In terms of hospital readmission, 2 out of 13 patients who underwent LIHR in Vigneswaran et al.'s study required hospital readmission. Conversely, three patients in the current study required hospital readmission within 30-day postoperatively, due to an surgical site occurrence procedural intervention, transient ischemic attack, and vomiting.
Hernandez-Rosa et al. have found the postoperative 30-day complication rates as 25.8% for laparoscopic repairs (31) and 9.6% for open repairs (73). Urinary retention was a common complication in the laparoscopic group. Vigneswaran et al. reported seven postoperative complications in 13 octogenarians who underwent LIHR. Among the complications, seroma and urinary retention were the most common complications. In the current study, although the overall complication rate was found as 28.6%, the majority of complications were classified under CD-Grades 1 and 2. Similar to previously mentioned studies, seroma and urinary retention were the most common complications in our study.
This study's retrospective design carries an inherent selection bias. Another drawback of the study is the lack of frailty scores to better assess patient baselines and subsequent functionality. Moreover, the absence of substantial adverse outcomes may be due to the limitations such as the lack of patient-reported outcomes and quality of life assessments. Furthermore, patients who sought medical attention or were admitted at outside hospitals due to complications after RIHR could not be tracked, and so, the results of this study may not have captured all outcomes. Multi-center studies with a larger and more diverse sample population may improve the generalizability of these results.
| Conclusion|| |
To our knowledge, this is the first study to present the outcomes of RIHR in patients aged 80 and above. Our results reveal short operative times and LOS, as well as the absence of conversions. Low perioperative morbidity and the absence of postoperative mortality support the feasibility of RIHR in these patients and are comparable to that of its historical counterparts. Studies with larger sample sizes would likely identify the relevant risk factors for the development of complications after RIHR in this population.
This study was approved by the local ethical committee (IRB#:HW202, 03/2019, St. Elizabeth's Medical Center).
Financial support and sponsorship
Conflicts of interest
Dr. Kudsi has received a teaching course and/or consultancy fees from Intuitive Surgical, Bard-Davol and W.L. Gore outside the submitted work. Drs. Gokcal and Bou-Ayash have no conflicts of interest or financial ties to disclose.
| References|| |
Ger R, Monroe K, Duvivier R, Mishrick A. Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg 1990;159:370-3.
Bloom DE, Mitgang E, Osher B. Demography of Global Aging; 2016.
de Goede B, Wijsmuller AR, van Ramshorst GH, van Kempen BJ, Hop WC, Klitsie PJ, et al
. Watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: A randomized controlled trial. Ann Surg 2018;267:42-9.
Weber DM. Laparoscopic surgery: An excellent approach in elderly patients. Arch Surg 2003;138:1083-8.
Mayer F, Lechner M, Adolf D, Öfner D, Köhler G, Fortelny R, et al
. Is the age of>65 years a risk factor for endoscopic treatment of primary inguinal hernia? Analysis of 24,571 patients from the Herniamed Registry. Surg Endosc 2016;30:296-306.
Köckerling F, Sheen AJ, Berrevoet F, Campanelli G, Cuccurullo D, Fortelny R, et al
. The reality of general surgery training and increased complexity of abdominal wall hernia surgery. Hernia 2019;23:1081-91.
Gokcal F, Morrison S, Kudsi OY. Robotic ventral hernia repair in octogenarians: Perioperative and long-term outcomes. J Robot Surg 2020;14:275-81.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-81.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.
Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: A novel continuous scale to measure surgical morbidity. Ann Surg 2013;258:1-7.
Muysoms FE, Deerenberg EB, Peeters E, Agresta F, Berrevoet F, Campanelli G, et al
. Recommendations for reporting outcome results in abdominal wall repair: Results of a Consensus meeting in Palermo, Italy, 28-30 June 2012. Hernia 2013;17:423-33.
Daes J, Felix E. Critical view of the myopectineal orifice. Ann Surg 2017;266:e1-2.
Polanczyk CA, Marcantonio E, Goldman L, Rohde LE, Orav J, Mangione CM, et al
. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 2001;134:637-43.
Pokala B, Armijo PR, Flores L, Hennings D, Oleynikov D. Minimally invasive inguinal hernia repair is superior to open: A national database review. Hernia 2019;23:593-9.
Hernandez-Rosa J, Lo CC, Choi JJ, Colon MJ, Boudourakis L, Telem DA, et al
. Laparoscopic versus open inguinal hernia repair in octogenarians. Hernia 2011;15:655-8.
Hope WW, Bools L, Menon A, Scott CM 3rd
, Adams A, Hooks WB 3rd
. Comparing laparoscopic and open inguinal hernia repair in octogenarians. Hernia 2013;17:719-22.
Aghayeva A, Benlice C, Bilgin IA, Bengur FB, Bas M, Kirbiyik E, et al
. Laparoscopic totally extraperitoneal vs. robotic transabdominal preperitoneal inguinal hernia repair: Assessment of short- and long-term outcomes. Int J Med Robot 2020;16:e2111.
Dallas KB, Froylich D, Choi JJ, Rosa JH, Lo C, Colon MJ, et al
. Laparoscopic versus open inguinal hernia repair in octogenarians: A follow-up study. Geriatr Gerontol Int 2013;13:329-33.
Celio AC, Kasten KR, Pofahl WE 2nd
, Pories WJ, Spaniolas K. Causes of readmission after laparoscopic and open ventral hernia repair: Identifying failed discharges and opportunities for action. Surgery 2016;160:413-7.
Payiziwula J, Zhao PJ, Aierken A, Yao G, Apaer S, Li T, et al
. Laparoscopy versus open incarcerated inguinal hernia repair in octogenarians: Single-center experience with world review. Surg Laparosc Endosc Percutan Tech 2019;29:138-40.
Vigneswaran Y, Gitelis M, Lapin B, Denham W, Linn J, Carbray J, et al
. Elderly and octogenarian cohort: Comparable outcomes with nonelderly cohort after open or laparoscopic inguinal hernia repairs. Surgery 2015;158:1137-43.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]