AHSQC QI SummitDenver, CO

Robotic TAPP Anthony Iacco, MD, FACSMichigan Hernia Surgery

Beaumont Health

December 13, 2019

AHSQC Data (through Nov 1) All Primary Umbilical

N % Primary HerniaLap etep 22 91Lap IPOM 518 95Lap TAPP 73 99Open Mesh 3110 97Open NO Mesh 2676 98Rob etep 75 97Rob IPOM 534 95Rob TAPP 502 98

Surgeon, Site Volume

Surgeons Sites

Lap etep 8 9Lap IPOM 82 71Lap TAPP 19 19

Open Mesh 165 143Open NO Mesh 177 154Rob etep 26 26

Rob IPOM 62 61Rob TAPP 62 64

Surgeon Affiliation

Academic (%) Private (%) Private + Acad(%)

N

Lap etep 50 27 23 22

Lap IPOM 56 37 7 518

Lap TAPP 11 71 18 73

Open Mesh 42 38 20 3110

Open NO Mesh 61 24 15 2676

Rob etep 27 56 17 75

Rob IPOM 15 50 35 534

Rob TAPP 36 49 15 502

Patient Demographics

Age (median) Female (%) BMI (median)

Lap etep 55 27 33

Lap IPOM 52 31 34

Lap TAPP 54 18 32

Open Mesh 53 22 31

Open NO Mesh 51 31 28

Rob etep 54 31 33

Rob IPOM 53 30 33

Rob TAPP 51 22 32

Focus in….

Clean (Class 1) %

Open Mesh 98

Open NO Mesh 93

Rob IPOM 99

Rob TAPP 99

Hernia Dimensions, Mesh Size (mean)

Width (cm) Length (cm) Mesh Width (cm) Mesh Length (cm)

Open Mesh 2 3 6 4

Open NO Mesh 1 1 NA NA

Rob IPOM 2 3 11 12

Rob TAPP 2 3 10 13

Hernia Grade (VHWG)

Grade 1 Grade 2 Grade 3

Open Mesh 1091 (35) 1954 (63) 58 (2)

Open NO Mesh 1313 (49) 1165 (44) 181 (7)

Rob IPOM 140 (26) 382 (72) 12 (2)

Rob TAPP 142 (28) 354 (71) 6 (1)

Comorbidities

Prevalence ALL Comorbidities %

Smoking w/in Year % Diabetes %

Open Mesh 56 11 12

Open NO Mesh 46 12 8

Rob IPOM 63 15 17

Rob TAPP 58 14 14

Operative Time

0-1 (hr) 1-2 2-3 3-4 4+

Open Mesh 70 24 5 1 1

Open NO Mesh 72 21 5 1 1

Rob IPOM 48 38 9 4 1

Rob TAPP 20 60 15 5 1

Rob TAPP

• Fascial closure rate 98%• Mesh used 100%• Permanent Synthetic >99%

Mesh Fixation – Rob TAPP

Mesh Fixation 404 (80%)

Adhesives 2

Staples 0

Sutures 393

Tacks 13

Length of Stay

• Open Mesh, Open NO Mesh, Rob IPOM = 0• Rob TAPP mean LOS = 1• Rob TAPP median LOS = 0

ComplicationsOpen Mesh Open NO Mesh Rob IPOM Rob TAPP

Any Complication 186 (7) 116 (5) 16 (4) 15 (4)

-PE 0 2 0 0

-MI/Arrest 3 0 0 0

-Prosthesis failure 0 0 0 0

-Pain requiring interv 0 0 1 0

-Other 10 14 2 2

SSI

SSI SSI req TX SSI req Procedure

Open Mesh 32 (1) 32 (1) 14 (1)

Open NO Mesh 13 (1) 12 (1) 7 (<1)

Rob IPOM 2 (<1) 2 (<1) 1 (<1)

Rob TAPP 3 (<1) 3 (1) 2 (<1)

All SSI were Superficial (except 8 Deep incisional SSI in Open Mesh group)

SSO exclusive of SSI (SSO-EI)

SS0-EI Hematoma Seroma Wound cellulitis

Wound serous drainage

Open Mesh 134 (5) 15 67 18 18

Open NO Mesh 73 (3) 6 42 8 10

Rob IPOM 8 (2) 0 6 0 1

Rob TAPP 8 (2) 0 5 0 1

SSI/O

SSI/O total SSI/O req Tx SSI/O req procedural intervention

Open Mesh 157 (6) 97 (4) 58 (2)

Open NO Mesh 85 (4) 29 (1) 18 (1)

Rob IPOM 10 (2) 5 (1) 4 (1)

Rob TAPP 11 (3) 4 (1) 2 (<1)

Post-op 30 day outcomes

Emergency Room Visit

Reoperation Hernia RECURRENCE

Open Mesh 48 (2) 15 (1) 3 (<1)

Open NO Mesh 48 (2) 10 (<1) 5 (<1)

Rob IPOM 14 (3) 3 (<1) 0

Rob TAPP 6 (1) 1 (<1) 0

Quality of Life, long term outcomes….• Data still being analyzed from statisticians, hopeful to have soon• Thanks for your help with this data Tom!

Year 1 f/u : 48 patients only Avg Pain 1: 81%Avg Pain 2: 9%Bulge : 9%

Year 2 f/u : 39 patient only Bulge : 3%

So what to do…

• I don’t know• I like the robotic TAPP for larger umbilical defects (>2cm)• See satellite defects• Mesh outside abdomen• Larger mesh than can place open • Flat mesh• Cheap mesh• Learning curve• Happy patients, good outcomes….so far• Need more follow up!

Thank you very muchAnthony Iacco, MD, FACSMichigan Hernia Surgery

Beaumont Health