870
whereas there is no significant difference regarding chronic
pain.7
Prosthetic mesh repairs have dramatically lowered the
recurrence rate following inguinal hernia repairs. In 2010,
a North American group of academic surgeons considered
the mesh use in inguinal hernia repairs as ‘‘one of the
dramatic innovations in modern surgical subspecialties.’’8
Meshes have certain concerns in clinical use; however,
their advantages outweigh their disadvantages and com-
plications together with recurrent and multirecurrent
cases.
In conclusion, we can question liberal use of pros-
thetic meshes for the treatment of inguinal hernias, but
abandoning the mesh use completely does not seem to be
logical at this stage and currently not concordant with the
evidence-based medicine. Instead, we can follow a
couple of ways to improve the outcomes after inguinal
hernia repairs. One of these is teaching our young
colleagues about detailed anatomy of the inguinal region
and regional nerves and how to deal with these structures
delicately and how to fix mesh carefully. Another way is
to perform tailored surgery for our patients according to
the type and characteristic of the hernias. The proper
technique might be a Lichtenstein repair, a laparoscopic
mesh placement, or a Shouldice operation. At this point, I
definitely agree with Professor Fischer that transversalis
fascia tissue repairs like Shouldice technique should be
a part of postgraduate education programs in general
surgery.
Skin grafts for the open abdomen
To the Editor:
I read with interest the article by Cheesborough et al,1
and was reminded of the adage that ‘‘everything old will
become new again.’’ Skin grafting was the default
technique to provide coverage of the open, frozen
abdomen after trauma, compartment syndrome, or
intra-abdominal catastrophe in the 1990s and 2000s in
many centers, especially those affiliated with regional
burn centers such as ours, where skin grafting was
already a frequently performed procedure. However in
doing large numbers of these grafts, several issues
were encountered. First, the skin grafts provide visceral
coverage but do nothing to oppose the lateral migration
of the recti, resulting in a gradual increase in the diam-
eter of the fascial defect and thus increasing the
complexity of the eventual definitive operation for hernia
repair. Second, in patients who have had the skin graft
for over 1 year, we would occasionally encounter the
‘‘burst’’ abdomen where the healed skin graft would
separate from the edges of the wound because of
increasing pressure from the herniation of abdominal
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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2019. Elsevier Inc. Todos los derechos reservados.
The American Journal of Surgery, Vol 208, No 5, November 2014
Hakan Kulacoglu, MD, FACS
Department of Surgery, RTE University School of
Medicine, Rize 53200, Turkey
http://dx.doi.org/10.1016/j.amjsurg.2013.12.043
References
1. Fischer JE. Hernia repair: why do we continue to perform mesh repair
in the face of the human toll of inguinodynia? Am J Surg 2013;206:
619–23.
2. Hindmarsh AC, Cheong E, Lewis MP, et al. Attendance at a pain clinic
with severe chronic pain after open and laparoscopic inguinal hernia re-
pairs. Br J Surg 2003;90:1152–4.
3. Ergül Z, Kulaçoglu H, Sen T, et al. A short postgraduate anatomy
course may improve the junior surgical residents’ anatomy knowledge
for the nerves of the inguinal region. Chirurgia (Bucur) 2011;106:
599–603.
4. Nordin P, Bartelmess P, Jansson C, et al. Randomized trial of Lichten-
stein versus Shouldice hernia repair in general surgical practice. Br J
Surg 2002;89:45–9.
5. Köninger J, Redecke J, Butters M. Chronic pain after hernia repair: a
randomized trial comparing Shouldice, Lichtenstein and TAPP. Langen-
becks Arch Surg 2004;389:361–5.
6. Bay-Nielsen M, Nilsson E, Nordin P, et al. Chronic pain after open
mesh and sutured repair of indirect inguinal hernia in young males.
Br J Surg 2004;91:1372–6.
7. Amato B, Moja L, Panico S, et al. Shouldice technique versus other
open techniques for inguinal hernia repair. Cochrane Database Syst
Rev 2012;4:CD001543.
8. Ball CG, Sutherland F, Kirkpatrick AW, et al. Dramatic innovations in
modern surgical subspecialties. Can J Surg 2010;53:335–41.
viscera, and the patient would present after sudden
rupture of the graft and intestinal eviscerationda signif-
icantly distressing event for the patient, as you would
imagine. Third, in a very small number of patients, the
‘‘pseudoperitoneum’’ between the healed skin graft and
the viscera would not form as it usually does and even
after 1 to 2 years, the skin graft would remain densely
adherent to the underlying intestine, preventing definitive
repair because of the high risk of enterotomy and fistula
while attempting to remove the skin graft.
The authors are to be congratulated on achieving
definitive repair of all their patients within a relatively short
time, thus avoiding the problems mentioned above. How-
ever, I would like to caution that this technique should be
applied judiciously; for example, trauma patients are
notoriously prone to attrition,2 so these results may not be
generalizable to all populations, especially those of rural
centers with a large and far-flung draw area. Therefore,
while skin grafting over a frozen abdomen is indeed a
safe, effective, and easy method of visceral protection, it
should probably still be considered a salvage option
compared with definitive abdominal closure with fascial
Letters to the Editor
approximation, except in cases of concomitant enteroatmo-
spheric fistula.
Sharmila Dissanaike, MD, FACS
Texas Tech University Health Sciences Center, Lubbock,
TX, USA
http://dx.doi.org/10.1016/j.amjsurg.2014.04.011
The meaning of surgeon’s comfort in robotic
surgery
To the Editor:
In robotic surgery literature, no studies focus on the
concept of surgeon’s comfort. This is likely because of the
extreme difficulty in quantifying the parameter ‘‘comfort’’
with statistical or mathematical methods, thereby prevent-
ing its use as a favorable criterion for the adoption of this
new technique.
We believe that the robot could carry all the advantages
of minimally invasive surgery, such as reduction in post-
operative pain, decreased length of hospital stay, rapid
patient rehabilitation, and better cosmetic results, to all
those patients for whom laparoscopy often is not an option.
This is the case, for instance, of hepatobiliary surgery in
which the robot can increase safety, feasibility, and efficacy
of minimally invasive surgery that has already been
established with this approach for other surgical procedures.
In urological practice, the advantages of the robotic
method have been widely demonstrated primarily in terms
of nerve sparing and more accurate lymphadenectomy.1
Some resistance against the use of robotic assistance
seems to persist in General Surgery, where the scarcity of
prospective data in terms of patients’ benefits makes it
difficult to justify the use of robotic assistance and to shun
the opinion that it constitutes, at best, a waste of resources.
We would like to point out here that shorter hospital stay
and swifter patient recovery represent a sizable decrease in
medical cost, and this has to be taken into consideration
when comparing the overall investment involved in the use
of robotic assistance with the overall cost of more
traditional surgery.2
In addition to this, robotic assistance provides non-
negligible comfort to the surgeon, and this can have very
favorable windfall profits on the chance of positive
outcome of surgical interventions.
As a matter of fact, the various degrees of freedom of the
robotic instruments allow the surgeon to replicate move-
ments of the traditional open technique that the rigidity of the
laparoscopic instruments does not allow. It also limit the
consequences of the natural tremor of surgeon’s hands by
converting movements into micro-movements, which are
displayed by 3D stable optical images.
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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2019. Elsevier Inc. Todos los derechos reservados.
871
References
1. Cheesborough JE, Park E, Souza JM, et al. Staged management of the
open abdomen and enteroatmospheric fistulae using split-thickness skin
grafts. Am J Surg 2014;207:504–11.
2. Stone Jr ME, Marsh J, Cucuzzo J, et al. Factors associated with
trauma clinic follow-up compliance after discharge: experience at
an urban level I trauma center. J Trauma Acute Care Surg 2014;
76:185–90.
All these factors represent a valuable advantage also
when compared to the long and complex laparoscopic
surgical interventions that induce mental and physical
stress and may well lead to a progressive decrease of the
surgeon’s performance.
Furthermore, Ji et al3 tried to demonstrate that robotic
surgery presents smaller rates of intraoperative bleeding
and conversion to laparotomy than traditional laparoscopy.
All this could be the consequence of 3D visualization of
the operative field and of the mechanics of the endowrist,
which facilitates micro-suturing and a more efficient
positioning of the clips.
The comfort comes also from the fact that robotic
assistance help in decreasing the number of cases required
to achieve competency for a given procedure, and enables
surgeons with less extensive laparoscopic experience to
undertake major surgical intervention.4,5
In centers with double console robot ensures an
extraordinary educational advantage both for the teacher
and his ‘‘students’’ in learning a new technique with direct
and interactive supervision which could also be more
effective and easier than the methods of teaching tradi-
tional surgery.
Robotic assistance facilitates complex interventions,
particularly the ones considered being ‘‘too risky’’ to be
undertaken in laparoscopy and for which an increased
comfort with long-lasting precision of gesture offers
paramount advantages for the outcome of the intervention
(considering, above all, that still today no more than just
30% of colorectal surgery occurs in laparoscopy).6
Regarding liver surgery, many aspects highlight the gain
derived from a robotic approach.
Casciola et al7 have already pointed out that the use of
the robot allows surgeons to approach those lesions
(whether CRLM or HCC) localized in the higher and pos-
terior segments of the liver (1, 4a, 7, 8) ensuring the oppor-
tunity to provide that parenchymal savings, which is
currently considered the therapeutic gold standard, and it
is often technically not feasible with laparoscopy (with
the need to perform major hepatectomies).
In this field, the chapter of nodes and sutures with
minimally invasive technique is a crucial issue. Indeed, the