Vahagn C. Nikolian

Traumatic abdominal wall hernia (TAWH) is an uncommon but clinically important consequence of both blunt and penetrating abdominal trauma. It is defined by disruption of the abdominal wall musculature and fascia with herniation of intra-abdominal or retroperitoneal contents through the defect. Although penetrating abdominal wall defects are usually apparent and can often be primarily closed during operative exploration, blunt TAWH is significantly more heterogeneous and challenging. The skin may remain intact while the muscle, fascia, neurovascular supply, and bony attachments are disrupted. The reported incidence of TAWH varies according to imaging strategy and trauma population, but frank herniation remains rare, occurring in <1% of blunt trauma patients in most contemporary series. The major management challenge is deciding whether the patient requires immediate trauma laparotomy or laparoscopy, acute abdominal wall repair, staged management with same-admission repair, or delayed hernia repair/abdominal wall reconstruction. Evidence remains primarily dominated by retrospective single-center series, multicenter registry studies, and systematic reviews with heterogeneous definitions and follow-up. Although traditional dogma had taught that these repairs should always be performed in a delayed fashion, recent multicenter data, systematic reviews, and surgeon experience suggest that timing of repair, type of repair, and mesh use must be individualized; bowel injury, contamination, defect location, and patient physiology are more important than a universal early-versus-delayed algorithm. This article summarizes the practical issues the trauma and acute care surgeon needs to know: diagnosis, classification, associated injuries, indications for exploration, repair timing, operative strategy, management of lateral and posterior defects, mesh use in contaminated fields, and associated outcomes.

Purpose During the COVID-19 pandemic, digital encounters became a crucial means of maintaining access to care amid restrictions on in-person interactions. As these limitations ease, it is essential to evaluate the outcomes of telehealth-based consultations. Before the pandemic, telehealth was predominantly used in postoperative care for surgical populations. This study examines the safety and efficacy of telehealth-based consultations compared to traditional in-person preoperative evaluations for small ventral hernia repair, contributing to the understanding of how telemedicine can be effectively integrated into surgical practices. Methods We utilized a prospectively maintained single-center database from a tertiary referral hospital with a specialized hernia and abdominal wall reconstruction team to compare preoperative, intraoperative, and postoperative variables between ventral hernia patients who received telehealth-based (phone or video) consultations and those who had any in-person clinic evaluation. Results A total of 187 patients with small (< 4 cm) ventral hernias were evaluated, with 42 (22%) being evaluated entirely through telemedicine-based consultations prior to their surgery. There were comparable post-operative outcomes for patients evaluated entirely virtually preoperative compared to those evaluated with at least one traditional in-person evaluation. In both cohorts, 52% of patients followed up at one-year through our hernia surveillance program. The unanticipated recurrence rates observed were 0% for digital pre-operative patients, and 2.01% for patients evaluated in person pre-operatively (p = 1). Conclusions Based on the data presented here, virtual preoperative encounters are as safe and effective as traditional in-person evaluations for patients with small ventral hernias.

Purpose In an era where telehealth is gaining traction within healthcare systems, its integration into preoperative assessment protocols presents both challenges and opportunities. Preoperative assessments have an important role in determining the best plan of action for each patient. Recent studies have reported adequate operative outcomes after telemedicine preoperative consultations. This study examines telehealth’s efficacy relative to traditional in-person evaluations in the context of preoperative consultations for inguinal hernia repairs and provides a deeper insight into how telemedicine might be utilized for pre-surgical assessments. Methods We analyzed a prospectively maintained single-center database at a tertiary referral hospital with a dedicated hernia and abdominal wall reconstruction center for pre, intra and postoperative variables comparing patients that received telemedicine (phone or video) preoperative consultations versus in-person clinic visits only. Secondary analysis with propensity score matching was employed to adjust for possible confounders. Results 265 patients that underwent inguinal hernia repair were included, with 60 encounters being telemedicine only and the rest in-person. This analysis found no difference in rates of postoperative complications between the telemedicine and in-person groups. The telemedicine group required less preoperative encounters with their surgeon (P < 0.001). In the preoperative in-person group, 41% switched to virtual follow-ups, while in the virtual group, only 18% chose in-person follow-ups (P = 0.003). Conclusions Based on our analysis, the use of telemedicine for preoperative assessments in inguinal hernia repairs as a feasible and safe choice for patients opting for this approach, potentially reshaping the preoperative paradigm in surgical practices.

Introduction: Options for minimally invasive ventral hernia repair continue to evolve as a function of our understanding of the abdominal wall and the development of new techniques. We describe a robotic transabdominal pre-peritoneal repair with concurrent rectus aponeuroplasty (TAPPRA) for incisional and recurrent ventral hernias.Methods: All patients in this retrospective cohort study underwent TAPPRA repair between October 2023 and March 2024. This study aimed to determine intraoperative feasibility of the technique and to assess immediate postoperative outcomes.Results: Twelve patients underwent TAPPRA repair for incisional and/or recurrent ventral hernias at an academic hernia center. The median case duration was 135 min with no significant intraoperative complications noted. Average defect size for the hernias measures 6.5 × 8.5 cm. Polypropylene mesh was used to reinforce all defects, with the average dimensions being 19.7 × 21.5 cm. 83% of patients were discharged within 24 h of their procedure. No significant postoperative complications were noted.Conclusion: We describe the first use of a novel ventral hernia repair technique, TAPPRA, and demonstrate that it is safe, feasible, and associated with appropriate short-term outcomes for repair of moderate sized incisional hernias.

Purpose Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias. Methods A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried. Results Sixty-seven male patients [median age: 51.6 years; interquartile range (IQR): 45–65 years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date. Conclusion We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.

Background Surgical videos coupled with structured assessments enable surgical training programs to provide independent competency evaluations and align with the American Board of Surgery’s entrustable professional activities initiative. Existing assessment instruments for minimally invasive inguinal hernia repair (IHR) have limitations with regards to reliability, validity, and usability. A cross-sectional study of six surgeons using a novel objective, procedure-specific, 8-item competency assessment for minimally invasive inguinal hernia repair (IHR-OPSA) was performed to assess inter-rater reliability using a “safe” vs. “unsafe” scoring rubric. Methods The IHR-OPSA was developed by three expert IHR surgeons, field tested with five IHR surgeons, and revised based upon feedback. The final instrument included: (1) incision/port placement; (2) dissection of peritoneal flap (TAPP) or dissection of peritoneal flap (TEP); (3) exposure; (4) reducing the sac; (5) full dissection of the myopectineal orifice; (6) mesh insertion; (7) mesh fixation; and (8) operation flow. The IHR-OPSA was applied by six expert IHR surgeons to 20 IHR surgical videos selected to include a spectrum of hernia procedures (15 laparoscopic, 5 robotic), anatomy (14 indirect, 5 direct, 1 femoral), and Global Case Difficulty (easy, average, hard). Inter-rater reliability was assessed against Gwet’s AC₂. Results The IHR-OPSA inter-rater reliability was good to excellent, ranging from 0.65 to 0.97 across the eight items. Assessments of robotic procedures had higher reliability with near perfect agreement for 7 of 8 items. In general, assessments of easier cases had higher levels of agreement than harder cases. Conclusions A novel 8-item minimally invasive IHR assessment tool was developed and tested for inter-rater reliability using a “safe” vs. “unsafe” rating system with promising results. To promote instrument validity the IHR-OPSA was designed and evaluated within the context of intended use with iterative engagement with experts and testing of constructs against real-world operative videos.