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Editorial
Minimally invasive surgery of the abdominal wall and clinically meaningful benefit. What are we talking about?
Cirugía mínimamente invasiva de la pared abdominal y beneficio clínicamente significativo. ¿De qué estamos hablando?
Manuel López Canoa,b,c
a Profesor Titular de Cirugía, Universidad Autónoma de Barcelona, Barcelona, Spain
b Coordinador de la Unidad de Cirugía de la Pared Abdominal, Hospital Universitario Vall d’Hebron, Barcelona, Spain
c Coordinador de la Sección de Pared Abdominal de la Asociación Española de Cirujanos (AEC), Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Excluding inguinal hernias&#44; the repair of abdominal wall defects with mesh using a minimally invasive &#40;MI&#41; approach has undergone a revolution in the last decade&#46; The improvement in the knowledge of the technique and of the anatomy means that not only the intraperitoneal approach &#40;ie&#44; laparoscopic&#41; is contemplated&#44; but the extraperitoneal approach &#40;ie&#44; endoscopic&#41; has also been introduced&#46; In this context&#44; a surgeon has in his MI therapeutic arsenal&#44; on the one hand&#44; intraperitoneal approaches such as the IPOM<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> technique&#44; the IPOM plus<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> technique&#44; the transabdominal preperitoneal technique&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> the retrorectal transperitoneal technique &#40;Rives-Stoppa&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the LIRA<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> or the TAR<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> technique&#44; in addition to extraperitoneal approaches such as the eTEP-RS technique &#40;Rives-Stoppa&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> the MILOS<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> technique&#44; eTEP-TAR<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#44; the SCOLA technique&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> the ELAR technique<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> or the endoscopic separation of components&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Furthermore&#44; if the Da Vinci&#174; robotic platform &#40;Intuitive&#41; is available&#44; the vast majority of the previously mentioned procedures can be performed with it&#44; both intraperitoneal and extraperitoneal&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is not surprising then that&#44; given this &#8216;wave&#8217; of techniques&#44; a surgeon who wants to perform an MI approach for the abdominal wall may have doubts regarding the best technique option for a patient and may wonder if all provide a &#8216;clinically significant benefit&#8217;&#46; It is difficult to precisely define what a &#8216;clinically significant benefit&#8217; means&#58; something seen from the perspective of a surgeon&#63;&#44; from the perspective of an individual surgeon or a group of surgeons&#63;&#44; from the perspective of the patient&#63;&#44; the perspective of an individual patient or of a group of patients&#63;&#44; from the administrator&#8217;s perspective&#63;&#44; from the politician&#8217;s perspective&#63;&#44; or from the perspective of other professional groups involved in patient care&#44; such as nursing staff or anesthetists&#63;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is not my intention to debate these issues here&#46; Others have previously attempted to clarify<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> what &#8216;clinically significant benefit&#8217; means by highlighting that among the complexities surrounding the notion of this idea&#44; a fundamental confusion is the merging of two different and equally important types of significant change&#46; On the one hand&#44; the concept of change that is <span class="elsevierStyleItalic">perceptible</span> to the patient or caregiver&#44; and on the other hand the concept of change that is considered <span class="elsevierStyleItalic">valuable</span> by the patient or caregiver&#46; In the context of MI surgery of the abdominal wall &#40;without forgetting that this surgery is overwhelmingly performed in &#8216;benign&#8217; settings&#44; with implications for the patient&#44; surgeon and society&#41;&#44; a <span class="elsevierStyleItalic">perceptible</span> change is something appreciable &#40;disappearance of the &#8216;lump&#8217;&#44; aesthetic improvement&#44; functional improvement&#44; disappearance of symptoms&#41;&#46; A valuable change is something useful&#44; which &#8216;was worth it&#8217; &#40;fewer short- and long-term complications&#44; shorter hospital stay&#44; less acute or chronic pain&#41; or perhaps simply that the patient perceives it as &#8216;better&#8217; or more &#8216;effective&#8217; compared to previous procedures&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In my opinion&#44; the &#8216;clinically significant benefit&#8217; of wall surgery may be inevitably linked to a <span class="elsevierStyleItalic">perceptible</span> change&#44; but above all it is imperative and perhaps mandatory that it be linked to a <span class="elsevierStyleItalic">valuable</span> change for the patient&#46; In any case&#44; and from our point of view&#44; these thoughts on the &#8216;clinically significant benefit&#8217; are nothing more than providing an opinion from another perspective of evidence-based surgery&#44; which&#44; it should be remembered here&#44; is based on its definition in three basic columns&#58; first&#44; the data present in the literature on a specific topic&#59; second&#44; the surgeon&#8217;s knowledge of these data combined with her&#47;his own experience of the subject in question &#40;in this case&#44; MI surgery of the abdominal wall&#41;&#44; and the third&#44; the patient&#8217;s values and preferences regarding the wall defect&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All the new MI techniques that are currently available in abdominal wall surgery require data collection for their results in the short&#44; medium and long term&#46; Surgeons should be aware of the results of these techniques so that&#44; in the end&#44; after discussing with the patient the characteristics of the process and the potential benefits and disadvantages of the different therapeutic options&#44; the latter can make a decision based on values and preferences and in the context of a shared decision&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The shared decision can be seen as a mechanism for presenting evidence to an individual patient in order to personalize the clinical decision&#46; It is a continuum&#44; along which the extent to which the patient or surgeon takes responsibility for the decision-making process varies&#58; at the extremes are decisions led by surgeons and decisions made by patients&#44; with many other possibilities in between&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In my opinion&#44; the best setting for evidence-based MI abdominal wall surgery is in the context of specialized units&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which should be accredited or certified by a society interested in abdominal wall problems &#40;nationally or internationally&#41;&#46; These units should perform a higher volume of cases in all types of wall surgery compared to an average general surgery department&#44; and they should be made up of experienced abdominal wall surgeons for all types of wall surgery recommended in the guidelines&#46; Furthermore&#44; these surgeons should be responsible for wall surgery education and training in their department&#44; and they should treat patients in accordance with current guidelines and scientific recommendations&#46; Each case should be documented prospectively in a quality control registry or database and&#44; of course&#44; surgeons must follow-up their patients to compare their own results with the reference data to with the aim of continuously improving their treatments&#46; This guarantees their contribution to the research in the therapeutics of abdominal wall problems&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Reading these lines&#44; some surgeons may think that specialized units cannot be organized in their hospitals given the particular &#8216;care&#8217; characteristics&#44; and that wall surgery in their hospitals will only be performed by surgeons with &#8216;special interest&#8217;&#46; However&#44; even in these cases&#44; those surgeons with &#8216;special interest&#8217; should be accredited&#44; trained and habitually register data&#46; There is probably a way to go in all of these facets of abdominal wall surgery&#46; Even so&#44; I believe that only in this way will it be possible to answer that MI techniques have a &#8216;clinically significant benefit&#8217; in abdominal wall surgery with a <span class="elsevierStyleItalic">perceptible</span> effect&#44; of course&#44; but one that is above all <span class="elsevierStyleItalic">valuable</span> for our patients&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez Cano M&#46; Cirug&#237;a m&#237;nimamente invasiva de la pared abdominal y beneficio cl&#237;nicamente significativo&#46; &#191;De qu&#233; estamos hablando&#63; Cir Esp&#46; 2021&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.cireng.2020.01.016">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;cireng&#46;2020&#46;01&#46;016</span></p>"
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