Laparoscopic-Guided Transversus Abdominis Plane Block for Postoperative Pain Management in Minimally Invasive Surgery: Systematic Review and Meta-Analysis. Hamid H, Emile SH, Saber AA, Ruiz-Tovar J, Minas V, Cataldo TE. J Am Coll Surg. 2020 Sep;231(3):376-386.
Minimally invasive approach has been increasingly used in abdominal surgery because it is associated with reduced morbidity and improved functional recovery without compromising surgical outcome. However, optimal postoperative pain therapy for patients undergoing minimally invasive surgery remains controversial.
The authors conducted a systematic review on 19 RCTs that included a total of 1,983 patients (979 in the Laparoscopic -guided Transversus Abdominis Plane group, and 1,004 in the control group). Randomized controlled trials (RCTs) comparing Laparoscopic- guided Transversus Abdominis Plane block(L-TAP) with an active comparator or inactive control (placebo or “no treatment”), studies including patients undergoing only minimally invasive surgery (i.e., laparoscopic, and robotic abdominal procedures), and reporting on at least one of the following outcome measures: postoperative pain scores at 0-4,48 hours and opioid consumption were included. Sample size was not required for inclusion in the analysis.
The primary outcome looking at: pain scores at rest and 24 hours postoperatively demonstrated no significant difference for L-TAP compared with ultrasound guided Transversus Abdominis Plane block (US-TAP) (MD -0.44, 95%CI [-1.17, 0.29], p = 0.24). L-TAP provided statistically, but not clinically, better postoperative pain control at rest at 24 hours compared with local infiltration analgesia (LIA) (MD-0.57, 95% CI [-0.94, -0.19], p = 0.003). No significant difference was demonstrated for L-TAP compared with inactive control regarding pain scores at rest at 24 hours postoperatively (MD -0.82, 95% CI [-1.66, 0.02], p = 0.06). However, the difference reached clinical significance (MD -0.95, 95% CI [-1.70, -0.21], p = 0.01) after removal of the only study with high pain scores. Heterogeneity was considerable (F= 97%, p < 0.001), and could not be explained by the type of surgical procedure nor time of block performance. The secondary outcome suggested, no significant difference between L-TAP and US-TAP regarding pain scores at 0 to 4 and 48 hours postoperatively both in rest and while moving. Compared with both LIA and inactive control L-TAP provided clinically better pain control at 0 to 4 hours postoperatively in rest and on movement. A significant diminution of opioid consumption was demonstrated for L-TAP compared with US-TAP during the 48 hours (MD-3.22 mg morphine, 95% CI [-5.60, -0.84], p = 0.008), but not the 24 hours, after surgery. L-TAP was favored in terms of length of hospital stay with ERAS program. The limitation of this review is presence of significant heterogeneity observed in most comparisons.
Overall, the authors concluded a, L-TAP provides comparable analgesia as US-TAP and is more effective than LIA with respect to early pain control. 24-hour opioid consumption, incidence of PONV, functional recovery, bowel function, and hospital stay were not significantly different between the 2 methods for TAP block. Future studies should focus on procedure-specific outcomes, type and concentration of local anesthetic drug administered (i.e., dose-ranging studies), as well as directly comparing L-TAP with epidural analgesia.
Robotic surgery in emergency setting: 2021: WSES position paper. de'Angelis N, Khan J, Marchegiani F, Bianchi G, Aisoni F, Alberti D, Ansaloni L, Biffl W, Chiara O, et al. World J Emerg Surg. 2022 Jan 20;17(1):4.
Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS), being routinely used for various aspects of elective surgery. Some early experiences have been reported in literature with regards to use of Robotics in the emergency setting.
The authors present a position paper supported by the World Society of Emergency Surgery (WSES) with an aim to provide a systematic review of the literature investigating the use of robotics in emergency general surgery to develop consensus statements based on the currently available evidence and practice. A total of 10 studies with 279 patients were included in the review. Qualitative synthesis of literature was conducted on emergency surgeries for hiatus hernia, gall bladder, bariatric. procedures and abdominal wall procedures using Robotics. Six position statements were put forward.
PS-1. Robotic surgery in emergency settings is highly dependent on the surgeon’s experience and should only be performed in an appropriately equipped operating room with trained nursing staff.
Successful implementation of robotic practice relies on a structured training curriculum, a dedicated surgical team, the institution’s support, and many other variables in addition to the training at the robotic console itself. In relation to duration of procedure, if the entire team is appropriately trained and prepared, the in-room-to-surgery-start time is reduced and has no significant impact on the overall duration of the scheduled emergency procedure.
PS-2. Robotic surgery in emergency settings may be considered in highly selected clinically stable patients only.
Careful patient selection is advised in order not to expose frail or unstable patients to longer emergency procedures or unnecessary complications related to the surgical technique.
PS-3 Robotic surgery may be considered in challenging situations, which are foreseen as a reason for conversion to open surgery if operating in laparoscopy.
The technological advances of the robotic surgical platform, such as deep magnification, 3D stereoscopic vision, a stable field with elimination of physiological tremors, motion scaling, and improved ergonomics as compared to laparoscopy, may contribute to facilitate the performance of some difficult procedural steps and reduce the risk of conversion. However, this remains to be proven, especially for surgical interventions performed in emergency settings.
PS-4. In a near future, robotic surgery may offer the advantage of tele mentoring and telesurgery, which could be useful to promote a safe and standardized application of robotics, also in low-volume centers or specific environments.
Since we are in a pandemic, maximal experience improves outcomes in emergency surgery, it would be beneficial to have a mentor observing and remotely participating in the intervention. Additionally, this technology could be applied to provide surgical care to rural areas, to establish surgical collaborations, and to eliminate the shortage of surgeons.
PS-5. The use of robotic surgery for unscheduled and urgent operations needs to be implanted without creating scheduling conflicts in the occupation of the operating room. Moreover, the increased costs need to e justified in the context of an efficient implementation of robotic surgery. Currently, the availability and accessibility of the robotic platforms for emergency care surgical units are very limited.
The availability of the platform during the night shift could potentially favor a more cost-effective use of the robotic system. However, this remains very limited.
PS-6 The development of new modular robotic platforms may contribute to increase the applications of robotic surgery in emergency settings.
The potential applications and outcomes of new platforms for robotic surgery in emergency setting need to be evaluated and updated once evidence is available.
Overall, the experts recognized that there is a substantial lack of evidence to support the use of robotic surgery for emerging general surgery procedures However, application of robotic surgical platform may grow with improvements in tele mentoring and telesurgery, which are particularly valuable in emergency settings.
Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial. Rosen MJ, Krpata DM, Petro CC, Carbonell A, Warren J, Poulose BK, Costanzo A, Blatnik J, Prabhu AS. JAMA Surg. 2022 Apr 1;157(4):293-301.
This study answers a question that we have been asking for a long time – can one use a synthetic mesh in a contaminated field? What is the recurrence rate of hernias with the use of synthetic and biologic mesh in these patients? The authors of the paper designed a single-blinded multicenter randomized controlled parallel-group trial comparing the use of biologic mesh and synthetic mesh in the single stage repair of clean-contaminated and contaminated ventral hernias. The primary outcome of the study was the efficacy of biologic mesh compared with synthetic mesh during single stage ventral hernia repairs in a contaminated field. The efficacy of each mesh was assessed by the 2-year hernia recurrence risk. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrences requiring procedural intervention, and 30-day hospital direct costs and prosthetic costs.
The authors demonstrated that there was substantial benefit of synthetic mesh over biologic mesh during single-stage ventral hernia repair in a clean-contaminated or contaminated surgical field in reducing hernia recurrence risk at 2-year follow up. The other question that was also answered was whether there was an increased risk of long-term mesh-related complications like chronic mesh infection with permanent synthetic mesh? The authors showed no difference in surgical site occurrence requiring procedural intervention between the two groups in the 2-year study period and there was no difference in mesh removal between the groups. This is significant in the light of the fact that no clear clinical benefit is seen with the use of biologic mesh over synthetic mesh in contaminated cases whereas there is a 200-fold increase in cost with the use of biologic meshes. Some of the limitations discussed included that the study only investigated 2 types of materials, medium-weight polypropylene and non-cross-linked porcine dermis, both placed in retro muscular position. And hence it may be difficult to extrapolate these findings to other types of meshes and other positions.
In conclusion, synthetic mesh demonstrates a lower recurrence rate versus biologic mesh in a single stage contaminated ventral hernia repair with similar safety outcomes and that the cost of the synthetic meshes are much lower than biologic mesh.
Robotic-assisted, laparoscopic, and open incisional hernia repair: early outcomes from the Prospective Hernia Study. LeBlanc KA, Gonzalez A, Dickens E, Olsofka J, Ortiz C, Verdeja JC, Pierce R. Hernia. 2021 Aug;25(4):1071-1082.
The Prospective Hernia Study is an ongoing, multicenter study comparing the clinical and subject-reported outcomes from Robotic surgery versus open and Robotic versus laparoscopic incisional hernia repair surgery in the United States. The objective of this study was to perform a comparative analysis of short- and long-term outcomes after open, laparoscopic and robotic incisional hernia repairs that include subject-reported hernia-related QOL. Some of the outcomes of interest were intraoperative and postoperative complications through the first 30 days after index surgery, subject reported QOL outcomes from baseline through 3 months based on the HerQLes abdominal questionnaire and subject reported pain medication use at 2-4 weeks post-surgery.
The authors demonstrated a longer operative time with robotic surgery vs laparoscopic surgery for ventral incisional hernia repair and a lower rate of conversion to open surgery for robotic surgery. When compared to open surgery the robotic group is associated with lower reoperation rate through 30 days, comparable operative time, and shorter LOS. The percentage of subjects who reported taking prescription pain medication was lower in robotic group (65.2%) vs open group (79.8%) or vs laparoscopic group (78.75%.)
In conclusion the operative outcomes were similar in the three groups except for a longer operative time with robotic surgery compared to laparoscopic surgery and lower rate of conversion to open surgery from Robotic in comparison to laparoscopic surgery and a lower percentage of patients who have had robotic surgery have the need for prescription pain medications compared to laparoscopic and open surgery. The study’s long-term follow-up will provide more evidence regarding QOL through 1 year and recurrence through 3 years.