Prof. Marc Miserez
Prof. R.J. Fitzgibbons
Prof. Volker Schumpelick
Sirs,
I have attempted to address your concerns in the revised manuscript. I propose listing the reviewers'
comments , followed by my proposed solution.
1.
"Materials: the reporting of good results would be more comprehensive if authors specify if
these results were obtained after reaching their learning curve or from initial experience, and
whether they had strangulated hernias and emergency cases"
Response:
2.
"Surgical technique: L50-54: The text of 'introduction of the 250mm cannula & the fulcrum...' is
unclear for non-robotic surgeons... What is the purpose of introducing prematurely the mesh, all
that time before its positioning..."
Response:
3.
If the reviewer is suggesting that the mesh used is too small, I have not found this to be
the case. The Progrip mesh used has approximately a 50% greater surface area than
what is recommended by the Lichtenstein Institute for an open repair (original text)
P5L45 . By adding "controlled placement of the mesh, centered on the defect" P5L48
reflects my finding that even for 2 cm defects the ability to precisely center the mesh on
the defect, allows for, at minimum a 4 cm overlap. The robotic instrumentation and
visualization are superior to what I can accomplish with laparoscopic instruments,
therefore obviating the need for very large pieces of mesh. I do acknowledge a
weakness with the paper in terms of short follow up (original text) P6L45
"On P4L11 if possible could the authors specify if the 9 recurrent hernias were unilateral"
Response:
5.
I appreciate the difficulty in conveying issues reflecting robotic instrumentation and
setup to non-robotic surgeons. I have included two new paragraphs that I feel succinctly
describe the robotic setup, as well as the rationale for the sequence of steps. P2L50P3L11
"I have personally tried this specific mesh in TEPP... I am concerned about the accuracy of your
results when using the same less moderate size of mesh for all patients, with a short follow up"
Response:
4.
I have added " this represented our initial experience with this novel technique" P2L13
The original text states "all cases were electively scheduled" - P2L15 - strangulated and
emergent cases are not electively scheduled.
All recurrent hernias were uniilateral P4L19
"I advise to delete Table 4"
Response:
6.
"P4L29 delete the "i" in the word was. L36: it would be better to add the percentage into
brackets"
Response:
7.
I agree with the concern over port site herniation. Why exchange one hernia for
another? From the beginning I spent time carefully closing the fascia to mitigate the risk.
I have been aware of the small bite - short stitch concept and have employed this, even
though it added to the overall length of the procedure. I have added description P3L52
to emphasize the importance of meticulous closure technique. As a side note, I have had
one port site hernia that developed in a cholecystectomy patient, in nearly 100
combined single site cases that I have performed.
"Why not inserting the port site transumbilically, ensuring better cosmetic outcomes, and
probably less incisional port hernia compared to lateral placement compared to lateral
placement of the single port"
Response:
9.
Changes made P4L35 and P4L42
"No port site hernias?? Be precautious... authors had only 15% obese patients: could it be of the
reason?"
Response:
8.
Table 4 has been deleted
I have clarified the location of the fascial incision based on "in order to efficiently
complete the proximal peritoneal flap dissection" P2L59-P3L6. There was never any
mention made of a lateral port placement. I am unsure of what the reviewer is
questioning.
" Discussion: Despite the improvement of the promissing challenging robotic single port surgery,
the cost effectiveness has not been assessed, compared to the higher price of the mesh, cost of
the single port, cost of the robotic accessory, longer operative time to the low-cost of
conventional laparoscopic surgery. Authors did not include in this article an assessment of cost
but I hope it would be done in the near future"
Response:
First, this is a descriptive paper showing that a novel technique is safe and effective.
Second, cost is highlighted as an important consideration, and in the original text time
equivalence to laparoscopic TEP and TAPP was shown, P6L24, as it is clear that operative
time is a substantial contributor to overall procedural costs. This is not a "longer
operative time" procedure as suggested by the reviewer.
I agree that cost issues need to be evaluated. I encourage the reviewers to look at
data emerging from several institutions - Green Bay, Minneapolis among others showing
that when you compare robotic single site cholecystectomy to laparoscopic
cholecystectomy, the robotic technique represents a higher contribution margin to the
hospital and is less costly for the patient. There are efficient systems that can bend the
cost curve down, making robotics the more financially attractive modality.
10.
"Two long in my opinion, and could be limited to 2 major messages"
Response:
I tried to increase the description and precision of the text, but was not successful in
making it substantially shorter. I clarified the important message that RASS-TAPP is safe
and should be evaluated further, as well as highlighting a potential advantage of this
technique over all other modalities of inguinal hernia repair, less risk of chronic pain.
Summary:
This was not mentioned by the reviewers, but I have reorganized the structure of the
Discussion, that I now feel is more cogently presented and easier to follow. I appreciate
the opportunity to revise the manuscript, and the time the reviewers spent
on the paper. Since I submitted this, there appears to be an increasing level of
awareness and enthusiasm for RASS-TAPP and I hope that you will allow this to reach a
much larger audience in Hernia.