Abdominal Wall Research Articles

Physical Activity and Exercise Interventions in Abdominal Wall Hernia Patients: Impact on Quality of Life and Health Outcomes - A Systematic Review and Meta-Analysis

ABSTRACT Objective Abdominal wall hernias are a common pathology in the surgical field, often leading to symptoms such as pain and tightness that can significantly reduce quality of life. Some studies have suggested that exercise and physical activity may improve both quality of life and health outcomes. This study aimed to evaluate the impact of exercise on quality of life and health outcomes in abdominal wall hernia patients through a qualitative systematic review and a quantitative meta-analysis. Design The systematic review identified six studies (n = 2409) that met the inclusion criteria, all demonstrating that exercise and physical activity positively affected health outcomes in abdominal wall hernia patients. Due to the limited number of studies available, the meta-analysis focused specifically on the effects of exercise and physical activity on quality of life and pain. Results The meta-analysis results indicated significant improvements in quality of life between pre- and postsurgery after a physical exercise intervention. However, no significant differences were found in pain levels between pre- and postsurgery following the exercise program. Conclusion This systematic review and meta-analysis offer promising insights into the potential benefits of physical activity and exercise interventions on health outcomes for AWH patients.

Percutaneous cryoablation in soft tissue tumor management: an educational review

Abstract Background Percutaneous cryoablation (PCA), having shown effectiveness in treating liver, lung, prostate, breast, and kidney tumors, is now gaining attention for the treatment of soft tissue tumors. PCA functions by freezing tissue, which induces ice crystal formation and cell death without damaging collagen structures. Technical considerations include the selection and handling of cryoprobes and cryogenic agents, procedural duration, and choice of image guidance for precision. This review aims to synthesize the mechanisms, applications, and technical aspects of PCA in the treatment of soft tissue tumors. Methods Adhering to PRISMA 2020 guidelines, a review was conducted of studies published prior to March 2024 that investigated PCA of soft tissue tumors. The review focused on technical and procedural aspects of cryoablation, cryobiological principles, cellular and tissue responses to extreme cold, intra- and post-procedure physiological mechanisms during and post-procedure, and main clinical applications. Results PCA is efficient in treating soft tissue tumors, including desmoid tumors, vascular malformations, and abdominal wall endometriosis. Several cryobiological mechanisms are involved, notably ice crystal formation, cellular dehydration, osmotic effects, and the inflammatory response, all of which contribute to its efficacy. Key technical aspects include the choice of cryoprobes, cryogenic agents (argon gas or liquid nitrogen), and the duration and control of freezing/thawing cycles. PCA also frequently outperformed traditional treatments like surgery and radiotherapy in terms of pain reduction, tumor size reduction, and patient outcomes. Moreover, its nerve sideration properties make it effective under local anesthesia. Conclusion Demonstrating substantial pain reduction, tumor size decrease, and high technical success rates, PCA offers a promising and minimally invasive alternative for soft tissue tumor treatment. Critical relevance statement Percutaneous cryoablation provides a minimally invasive, precise alternative for soft tissue tumor management, advancing clinical radiology by offering effective treatment with reduced patient risk and enhanced outcomes through image-guided procedures. Key Points Percutaneous cryoablation (PCA) offers a promising, minimally invasive alternative for managing soft tissue tumors. PCA employs image-guided techniques to accurately target and treat tumors, ensuring high precision and control. PCA preserves structures like collagen, reduces pain, decreases tumor size, and generally enhances patient outcomes. Graphical Abstract

Delayed vs single-staged abdominal wall reconstruction in contaminated ventral hernia.

When faced with contaminated ventral hernia repairs, surgeons must decide to repair the defect in a single-stage or delay the definitive repair until a clean scenario has been achieved. We sought to compare wound complications, long-term hernia recurrence and quality of life for patients who underwent delayed versus single-staged abdominal wall reconstruction (AWR) in the setting of clean-contaminated and contaminated wounds. The Abdominal Core Health Quality Collaborative was used to identify adult patients at our institution who underwent open AWR with retromuscular synthetic mesh placement between January 2014 and August 2023. The delayed group included patients who underwent clean-contaminated or contaminated abdominal operation in the setting of a ventral hernia without placement of permanent synthetic mesh, then underwent AWR with permanent synthetic mesh placement in a separate operation. The single-staged group had clean-contaminated or contaminated wounds concomitant with AWR. Outcomes of the AWR were compared. 63 patients underwent a delayed AWR and 375 patients underwent a single-staged AWR with a median(IQR) follow-up of 3(2,5)years. Most common concomitant procedures involved small intestine(30%) or hepatobiliary(30%). Most common index operations in delayed AWR were ileostomy(52.4%) and colostomy(14.2%) reversals. Median(IQR) time between initial operation and definitive AWR was 1.0 (0.7, 1.9)years. Median(IQR) hernia width was 11.35(8.4, 15.0)cm at initial operation and 16.0(15.0,20.0)cm at AWR for the delayed group(p < 0.001). Three patients (19%) in the delayed group and 14(12%) in the single-staged underwent wound debridement within 30-days(p = 0.46); a single patient in each required partial mesh excision within 30-days(p = 0.098). Wound morbidity, reoperation and hernia recurrence were similar (p > 0.05). In patients with a ventral hernia and separate indication for abdominal operation with a clean-contaminated or contaminated wound, either delayed or single-stage approaches to AWR may be viable.

The effect of clinically significant weight loss prior to open ventral hernia repair.

The study aim was to assess the impact of clinically significant weight loss (CSWL; ≥5% weight reduction) on postoperative complications following abdominal wall reconstruction with the component separation technique (CST). A retrospective review of patients who underwent open ventral hernia repair (VHR) with CST from November 2008 to January 2022 was performed. Cohorts were stratified by presence of CSWL from baseline weight at preoperative consultation. Of 180 total patients, 40 (22.2%) achieved CSWL prior to VHR. Mean age was 59.6 ± 11.2 years. Patients in the CSWL cohort represented a higher average body mass index (BMI) (33.6 vs. 31.7kg/m2, p = 0.076), and were obese more frequently (80.0% vs. 56.4%, p = 0.007). The CSWL cohort had a higher proportion of patients in Ventral Hernia Working Group (VHWG) classification II (82.5% vs. 63.6%) while the non-CSWL cohort had more VHWG classification III/IV (20.0% vs. 10.0%, p = 0.078). Mean follow-up duration was 6.1 ± 13.4 months. Complications, including 30- and 90-day surgical site occurrence (SSO), return to operating room, readmission, and hernia recurrence (CSWL: 5.0% vs. non-CWL 1.4%, p = 0.179), were comparable between cohorts. BMI was an independent predictor of any complication (OR 1.07, p = 0.044) and 90-day SSO (OR 1.10, p = 0.043). Achievement of CSWL prior to open VHR utilizing CST results in similar post-reconstruction outcomes to patients who maintained a comparable BMI at baseline. Higher day-of-surgery BMI was more consequential to postoperative complications than percent weight loss.

How I Do It: Madrid posterior component separation in 10 steps, with special consideration of its anatomy.

The Madrid Posterior Component Separation technique (Madrid PCS) is an approach for abdominal wall reconstruction that leverages anatomical landmarks to optimize outcomes. This manuscript describes ten essential steps for performing the Madrid PCS, focusing on technique, safety, and efficiency. A comprehensive step-by-step approach is outlined, beginning with the initial incision and adhesiolysis, progressing through retromuscular dissection, and concluding with lateral release and subxiphoid dissection. Emphasis is placed on key anatomical landmarks, tissue planes, and surgical maneuvers critical for each phase. Detailed tips and tricks, challenging scenarios, and potential risks are provided to enhance the reproducibility and safety of the procedure. Applying these ten steps provides an organized and methodical approach to the Madrid PCS. The focus on anatomical landmarks minimizes the risk of complications such as nerve injury, peritoneal tears, and inadvertent organ damage, while ensuring for the optimal placement of prosthetic materials. Adherence to these ten steps, based on anatomical landmarks, significantly improves the safety and effectiveness of the Madrid PCS technique. By understanding the nuances of the procedure, surgeons can achieve consistent and reproducible results in complex abdominal wall reconstructions.

Can Talaromyces marneffei Infection Cause Acute Liver Failure? A Case Report

Introduction: Talaromyces marneffei is a pathogen that causes talaromycosis, a systemic fungal infection. Cases in which hepatic failure is the primary clinical presentation are exceedingly rare. Case Presentation: This report details the case of a 49-year-old male with no prior liver disease, presenting to the hospital with persistent symptoms, including a fever lasting over ten days, abdominal distension for five days, and jaundice for three days. The patient’s history included immune thrombocytopenia and prolonged glucocorticoid therapy. Physical examination revealed yellowing of the skin and sclera, abdominal distension, firmness of the abdominal wall, absence of abdominal tenderness, positive shifting dullness, and pitting edema in the lumbosacral region and bilateral lower extremities. An HIV antibody test was negative. The patient developed hepatic failure and received artificial liver support along with routine therapy. Despite these interventions, the patient was automatically discharged without improvement and subsequently passed away. Post-discharge, cultures from pleural and abdominal effusions identified Talaromyces marneffei. Conclusions: Talaromyces marneffei infection should be considered in the differential diagnosis of immunocompromised patients, particularly those with no history of liver disease but with long-term glucocorticoid or immunosuppressant use who present with acute liver failure. Early and aggressive investigation for the causative pathogen is essential to minimize diagnostic and treatment delays. Given the prolonged incubation period of Talaromyces marneffei, metagenomic next-generation sequencing may offer a more rapid approach for etiological diagnosis.

Impact of glucagon-Like peptide-1 agonists in optimizing abdominal wall Reconstruction patients.

Pre-optimization of obese patients prior to abdominal wall reconstruction (AWR) is essential in mitigating their increased preoperative risks. Traditionally diet, exercising, bariatric surgery are the tools typically prescribed for weight loss. The advent of glucagon-like peptide-1 agonists (GLP-1A) which stimulate insulin secretion and inhibit gastric emptying have improved the weight loss armamentarium. However, there is a limited amount of literature on GLP-1A effectiveness and postoperative outcomes in AWR patients. This study compares the efficacy of GLP-1A to Bariatric Surgery (BAS) in perioperative AWR patient. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2021 and March 2024. We included patients who required GLP-1A or BAS for weight optimization prior to AWR. We excluded patients on GLP1-A or history BAS not performed for AWR preoptimization. Basic demographics such as age, sex, race, weight and BMI at initial clinic visit and at surgery were compared. Primary endpoints included time to surgery, time to bowel recovery and length of stay (LOS). Time to surgery was defined as the number of months between the initial clinic visit and AWR. Time to bowel recovery was defined as the number of days it took for the first postoperative bowel function. Secondary endpoints included standard 30-days postoperative variables. Nominal variables were analyzed using a Fisher exact test and continuous variables were analyzed with Student's T test. 35 patients were included in this study (GLP-1A: 17, BAS: 18). The GLP-1A cohort had a lesser BMI at the initial clinic visit (40.8 vs 43.4, p = 0.188). GLP-1A cohort made it to the operating room faster (9.1 months vs 13.5 months, p = 0.06) from the first clinic visit; and (7.9 months vs 9.7 months, p = 0.4) from initiation of weight loss intervention. Albeit losing less weight (14.9 kg vs 27.1 kg, p = 0.008) with a lesser reduction in the BMI (4.69 vs 9.23, p = 0.004). The GLP-1A cohort showed a non-significant elevated LOS (5.2 days vs 3.6 days, p = 0.25) and an increased ileus rate (17.6% vs 0%, p = 0.1). However, there were no differences noted in time to bowel recovery (2.9 days vs 3.1 days, p = 0.76). GLP-1A is effective in optimizing patients needing weight loss before AWR. They shorten the timeline to AWR intervention and have comparable peri-operative outcomes to BAS patients.

Effect of an abdominal binder on postoperative outcomes after ventral hernia repair: a systematic review and meta-analysis of randomized controlled trials.

Abdominal binders consist of a wide compression belt that encircles the abdomen, theoretically supporting the abdominal wall. However, their use after ventral hernia repair is debated. Therefore, this meta-analysis evaluates their efficacy. We searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing the effects of abdominal binders after ventral hernia repair. Outcomes included postoperative pain using the visual analog scale (VAS), surgical site infection (SSI), seroma formation and size, general well-being, activity limitation, forced expiratory volume in the first second (FEV1), and a 6-min walk test. Statistical analysis was performed with Review Manager 5.4.1 using a random-effects model. We included five RCTs encompassing 297 patients. Overall analysis showed decreased SSI rates (RR 0.21; 95% CI 0.07 to 0.59; p = 0.003; I2 = 0%) and reduced pain two weeks after surgery (MD -0.89; 95% CI -1.41 to -0.37; p = 0.0008; I2 = 0%) using abdominal binders. For patients undergoing open ventral hernia repair, it also demonstrated reduced SSI, pain four weeks after surgery (MD -0.60; 95% CI -0.88 to -0.32; p < 0.0001; I2 = 66%) and increased 6-min walk test performance four weeks after the procedure (MD 32.78m; 95% CI 15.28 to 50.29m; p = 0.0002; I2 = 0%). Abdominal binders may decrease SSI, postoperative pain, and increase physical condition, particularly in open ventral hernia repair. Further studies are still required to evaluate the role of abdominal binders in minimally invasive techniques.

The development, implementation, and evaluation of a pre-rotation quiz to improve resident preparedness for an abdominal wall reconstruction surgical rotation.

Although hernia repair constitutes a significant portion of surgical training, education around more complex hernia concepts such as abdominal wall reconstruction (AWR) or paraesophageal hernia repair may be lacking. We developed and implemented a pre-rotation quiz for residents on an AWR and minimally invasive surgery service. We also investigated the staff and resident perception of resident knowledge and experience of the rotation before and after quiz implementation. The multiple-choice quiz questions were written by clinical and research fellows, validated by four staff, two fellows, and two senior residents and implemented in June 2023. Questions assessed knowledge of anatomy, operative steps, mesh materials, clinical trials, and postoperative management specific to ventral, inguinal, and paraesophageal hernia repairs. Residents were notified of the summative quiz three weeks prior and provided with reference materials specific to quiz questions. Anonymous Likert-type surveys were distributed to staff and residents between 3/2023 and 3/2024. Responses were assessed based on the overall score as well as individual domains and then compared based on whether they were completed before or after implementation of the quiz. 17 seniors and 29 juniors rotated on service and all completed the pre-rotation quiz between 7/1/2023-3/4/2024. The mean first attempt score was 72%(± 12.4%) for junior residents and 88.4%(± 9.6%) for senior residents. Staff reported overall resident knowledge improved after quiz implementation (maximum 90, mean(SD): 46.25(± 8.58) vs. 75.5(± 11.24),p = 0.05). Sixteen(45.7%) residents responded to the survey before quiz implementation and 23(50%) after. Residents only reported improved knowledge regarding current literature (maximum 5, mean(SD):3.2 ± 0.98 vs. 3.8 ± 0.78,p = 0.04). Implementing a pre-rotation quiz effectively improves staff perception of resident knowledge and preparation.

Pre-vascularisation of the acellular bladder matrix using the omentum in a porcine model prior for bladder reconstruction-a step towards clinical application?

Research studies with porcine acellular bladder matrix (PABM) showed integration of only small sized stamps in recipient bladders, however for clinical use in bladder augmentation significantly larger patches are needed. We hypothesised pre-vascularisation with omentum may be a step towards clinical translation. Eight domestic pigs were operated three times 8-10weeks apart: 1-Implantation; PABM with recorded dimensions were sutured around a tissue expanding device, wrapped in omentum and sutured to the anterior abdominal wall. 2-Augmentation; hemi-cystectomy and bladder augmentation was performed with the pre-vascularized PABM using non-absorbable suture 3-Sacrifice; The dimensions of the PABMs were measured macroscopically, the in-vivo microcirculation of the PABMs were assessed using laser speckle contrast imaging. HE staining, uroplakin 3 and CK7 immunohistochemistry was performed. In seven animals, the bladder augmentation was successful without complication. One animal was lost in bowel obstruction and in two animals enteric fistula was found after the first intervention. The rectangular shape of the initial tissue expander was subsequently changed. All the seven patches were strong, compliant and had integrated with the surrounding native bladder and were 83% (48-100%) of the original patch size. Laser speckle contrast imaging already showed microcirculation at the patch edges at augmentation and this further improved towards the centre of the patches by the end of the study. Histology demonstrated acute inflammatory response with fibroblast infiltration after implantation and full coverage by urothelium was seen with positive staining for CK7 antibodies. Pre-vascularization of PABM in the omentum of healthy porcine models allows larger PABM patches to integrate this may be a step towards clinical application.

Minimally invasive intraperitoneal onlay mesh plus (IPOM +) repair versus enhanced-view totally extraperitoneal (e-TEP) repair for ventral hernias: a systematic review and meta-analysis.

Following concerns regarding an intraperitoneal mesh, newer ventral hernia repair (VHR) approaches focus on placing the mesh outside of the peritoneal cavity. The e-TEP technique used the retromuscular space and is suggested to be associated with decreased postoperative pain compared to IPOM +. This study aims to compare the IPOM + with the e-TEP for VHR. We searched for studies comparing endoscopic IPOM + and e-TEP in PubMed, EMBASE, and Cochrane databases from inception until September 2023. Outcomes were Visual Analog Scale (VAS) after 24 h of surgery and between 7 and 10 days after surgery, operative time, length of stay (LOS), seroma, recurrence, and readmission. RStudio was used for statistical analysis. Heterogeneity was assessed with I2 statistics, with random effect for I2 > 25%. From 149 records, 7 were included, from which 3 were RCTs, 3 were retrospective studies, and 1 was an observational prospective study. 521 patients were included (47% received e-TEP and 53% received IPOM +). 1 study included only robotic surgeries and 6 studies included only laparoscopy. Mean defect width was 3.62 cm ± 0.9 in the e-TEP group and 3.56 cm ± 0.9 in the IPOM + group. IPOM + had higher VAS after 1 day of surgery (MD -3.35; 95% CI -6.44; -0.27; P = 0.033; I2 = 99%) and between 7 and 10 days after surgery (MD -3.3; 95% CI -5.33, -1.28; P = 0.001; I2 = 99%). e-TEP repair showed with longer operative time (MD 52.89 min; 95% CI 29.74-76.05; P < 0.001; I2 = 92%). No differences were seen regarding LOS, seroma, recurrence, and readmission. The e-TEP repair is associated with lower short-term postoperative pain after VHR compared to IPOM +, but with longer operative time. More RCTs are required to assess these results with long-term follow-up and determine its role in the armamentarium of the abdominal wall surgeon.

Mechanisms of polyglycolic acid sheet-induced abdominal wall adhesions in hamsters.

A hamster adhesion model was used to investigate the mechanism by which polyglycolic acid (PGA) sheets reinforce the surgical site through the acceleration of postoperative adhesion formation. After receiving electrocautery burns on the inside of the abdominal wall, the hamsters were divided into the PGA group (a PGA sheet was placed on the burned area) and a non-treated group (a PGA sheet was not placed). The degree of adhesion was evaluated at 3, 14, 28, and 56days after burn injury, and the mRNA levels of myeloperoxidase (MPO), tumor necrosis factor (TNF)-α, and transforming growth factor (TGF)-β1 at the surgical sites were measured. Adhesion formation was observed 3days after the burn injury in the non-treated group, but it decreased at 14, 28, and 56days. On the other hand, a significant increase in adhesion formation was observed at 3days in the PGA group relative to the non-treated group, with the increase continuing at 14 and 28days. Significant increases in MPO, TNF-α, and TGF-β1 mRNA levels at the adhesion site were observed 3days after the burn injury in both groups, with the increase continuing in the PGA group, but not in the non-treated group, at 14 and 28days. Acceleration of adhesion formation by PGA may be associated with upregulated MPO, TNF-α, and TGF-β1 mRNA levels.

A Novel UBM/SIS Composite Biological Scaffold for 2-Year Abdominal Defect Repairing and Strength Recovery in Canine Model.

Biological scaffolds are widely utilized in hernia treatment due to their exceptional pro-regenerative properties, which mitigate scar formation. However, serious complications occurred, caused by inflammatory response, premature degradation, and mechanical failure. Consequently, improvements of the biological scaffold are necessary to mitigate these risks. In this study, a novel biological scaffold integrating basement membrane-containing urinary bladder matrix (UBM) and small intestinal submucosa (SIS) is developed, and its safety and effectiveness are assessed in comparison to a commercial SIS (c-SIS) scaffold. The introduction of UBM as top surface layers significantly promotes cell adhesion, facilitating rapid formation of isolated regeneration zone. Proteomic analysis has demonstrated a more efficientdecellularization of the UBM/SIS scaffold, which subsequently mitigates inflammation in murine models, and promotes the polarization of macrophages toward the pro-healing M2 phenotype in a rat model of abdominal wall muscle defect. Furthermore, a two-year repair trial is conducted on a full-thickness abdominal wall muscle defect in canine model and confirmed that the UBM/SIS scaffold exhibits reduced seroma occurrences and enhanced tissue repair performances. Overall, the efficacyof this novel biological scaffold suggests its potential to minimize hernia recurrence in clinical practice and mitigatepatient suffering from severe inflammatory responses.

HPB SO11 - Dropped Gallstones After Laparoscopic Cholecystectomy: An Umbrella Review

Abstract Background Gallstones (cholelithiasis) are solid formations in the gallbladder or biliary tract due to high cholesterol or bilirubin levels, affecting 10-20% of adults. Over 20% of those affected show symptoms like biliary colic. Gallstones can be cholesterol, black pigment, or brown pigment, with cholesterol stones being the most common. The persistence of gallstones following laparoscopic cholecystectomy (LC) poses a significant clinical challenge, potentially leading to morbidity and diagnostic complexities, often with delayed recognition. These complications can present as various intraabdominal conditions such as abscesses (intraabdominal or abdominal wall), fistula formation, peritonitis, bowel perforation, or ileus. Method We performed an extensive search of the academic literature spanning several databases, namely PubMed, Embase, Scopus, Web of Science, and Google Scholar. Inclusion criteria for this research encompassed systematic reviews, with or without meta-analysis, focusing on the examination of spilled gallstones in terms of signs, symptoms, diagnosis, imaging, and management. The assessment of potential bias in the final study selection was undertaken utilizing the R-AMSTAR and Risk of Bias in Systematic Reviews (ROBIS) assessment tools. Results The most prevalent sites for lost gallstones were identified as the right subhepatic, perihepatic, retroperitoneal, right flank, and pelvic regions. Multiple stones were found to be more common than single stones. Clinical presentations included the presence of abdominal masses simulating malignancy, intestinal obstruction, and pelvic pain or fistula formation. Surgical intervention emerged as the primary treatment approach. Pain localized to the right upper quadrant was reported by 24% of participants. Computed tomography (CT) was the most frequently employed diagnostic modality for stone identification (70.2%), followed by ultrasonography (US) (63.2%) and X-ray (42.9%). Conclusion Our research underscores a significant area that has received limited attention in existing literature. The occurrence of spilled gallstones presents challenges in diagnosis and carries the potential for severe post-laparoscopic cholecystectomy complications. A notable gap exists in the education of both surgeons and patients regarding this complication, emphasizing the need for heightened awareness among surgeons. Given the considerable variability observed between laparoscopic cholecystectomy procedures and the onset of associated symptoms, comprehensive studies with larger cohorts are imperative for elucidating pertinent risk factors and devising effective interventions.

EGS SO22 - When What Is Left Is Not Right

Abstract Background Aims We present a case of small bowel obstruction in a massive inguinoscrotal hernia, with loss of abdominal domain, treated successfully by emergency surgery. The chronicity of the condition resulted in a large pendulous pelvic stomach, with the Duodeno jejunal flexure within the hernia and constricted by the hernial ring. Method The first contact with surgical team was as emergency, since initial referral to surgical outpatients was deferred by the patient, due to his embarrassment. After initial attempts to decompress the stomach through nasogastric tube and with nutritional support with parenteral nutrition, the patient was counselled for surgery. Informed consent was taken for right orchidectomy, possibility of open abdomen with delayed reconstruction, stoma, respiratory compromise, multiorgan failure and death.Prior to intervention, Intensive Therapy unit was consulted for admission following surgery, with plans to use Botox in the abdominal wall, to improve compliance, in case of abdominal compartment syndrome or respiratory failure. Results Through an inguinoscrotal incision, the inguinal canal was opened and the cord structures were transfixed and divided. The internal ring was divided laterally to allow gradual compression and replacement of the hernia intraabdominally. Over 8 litres of fluid was removed from Nasogastric aspirate. Lymphoedema in the scrotum made the laterality of the testis seen in the operative field ambiguous. The hernia was repaired with Bassini repair of the muscles, followed by polypropelene mesh. Following surgery, patient was discharged home with no immediate complications. Histology of the sac and Tunica Vaginalis revealed an atrophic right testis. Conclusion Distorted anatomy from chronicity of common surgical pathology may present challenge to even experienced surgeons. Unusual presentation of common pathology requires thinking outside the box. Since the lymphoedema in the scrotal hernial sac made the laterality of the testis unclear, an informed decision was taken not to remove the single testis seen in the operative field. The histology confirmed that this was the right decision, since the atrophic right testis was included in the operative specimen. Post operative imaging confirmed what was left, was the left testis.

OGC SO41 - Omentopexy Technique in Robotic Assisted Minimally Invasive Oesophagectomy

Abstract Background Laparoscopic omentopexy has been shown to reduce the rates of post-oesophagectomy diaphragmatic hernia (PODH) in a retrospective cohort study in a UK specialist centre. We aimed to demonstrate the technique during robotic-assisted minimally invasive oesophagectomy (RAMIE) with video capture. Method The Versius (CMR Surgical) robotic system was used in the abdominal stage of RAMIE performed on a 63 year old male with a poorly differentiated oesophageal adenocarcinoma. No previous abdominal surgery had been performed on this patient. Video capture was used to record this part of the procedure. Results Ports were inserted in standard configuration to allow fashioning of a gastric conduit. Following this the greater omentum was secured to the anterior abdominal wall around the jejunostomy site. No immediate complications were observed. Conclusion The Versius system can be used to successfully perform omentopexy with standard port positioning. Omentopexy was successfully performed with no immediate complications, did not significantly prolong procedural time and may reduce risk of PODH. The authors support the use of this technique in robotic-assisted surgery for reducing risk of PODH and support further work to validate this technique in cohort studies.

Long-Term Outcomes of Component Separation for Abdominal Wall Hernia Repair.

Component separation is a reconstructive technique used to facilitate midline closure of large or complex ventral hernias. Despite a contemporary surge in popularity, the incidence and long-term outcomes after component separation remain unknown. To evaluate the incidence and long-term outcomes of component separation for abdominal wall hernia repair. This cohort study examined 100% Medicare administrative claims data from January 1, 2007, to December 31, 2021. Participants were adults (aged ≥18 years) who underwent elective inpatient ventral hernia repair. Data were analyzed from January through June 2024. Use of component separation technique during ventral hernia repair. The primary outcomes were the incidence of component separation over time and operative recurrence rates up to 10 years after surgery for hernia repairs with and without component separation. The secondary outcome was rate of operative recurrence after component separation stratified by surgeon volume. Among 218 518 patients who underwent ventral hernia repair, the mean (SD) age of the cohort was 69.1 (10.9) years; 127 857 patients (58.5%) were female and 90 661 (41.5%) male. A total of 23 768 individuals had component separation for their abdominal wall hernia repair. The median (IQR) follow-up time after the index hernia surgery was 7.2 (2.7-10) years. Compared with patients who did not have a component separation, patients undergoing repair with component separation were slightly younger; more likely to be male; and more likely to have comorbidities, including obesity, and had surgeries that were more likely to be performed open and use mesh. Proportional use of component separation increased from 1.6% of all inpatient hernia repairs in 2007 (279 patients) to 21.4% in 2021 (1569 patients). The 10-year adjusted operative recurrence rate after component separation was lower (11.2%; 95% CI, 11.0%-11.3%) when compared with hernia repairs performed without component separation (12.9%; 95% CI, 12.8%-13.0%; P = .003). Operative recurrence was lower for the top 5% of surgeons by component separation volume (11.9%; 95% CI, 11.8%-12.1%) as opposed to the bottom 95% of surgeons by volume (13.6%; 95% CI, 13.4%-13.7%; P = .004). This study found that component separation was associated with a protective effect on long-term operative recurrence after ventral hernia repair among Medicare beneficiaries, which is somewhat unexpected given the intent of its use for higher complexity hernias. Surgeon volume, while significant, had only a minor influence on operative recurrence rates.

Evidence-based Cesarean Delivery: Intraoperative management following placental delivery until skin closure (Part 9): Evidence based care during cesarean delivery.

This expert review provides recommendations for the cesarean technique after placental delivery to skin closure. Following placental delivery during cesarean, sponge curettage may be omitted as it has not been shown to decrease the risk of retained products of conception. Uterine irrigation and mechanical cervical dilation cannot be recommended. Either intra-abdominal or extra-abdominal repair of the hysterotomy is acceptable with some possible benefits with decreased postoperative pain and nausea/vomiting with intra-abdominal repair. There is insufficient evidence to recommend one uterine closure technique over the other with regards to suture type, continuous versus interrupted, locking or non-locking, one versus two-layer closure. Double layer uterine closure has been shown to be more beneficial with regards to residual myometrial thickness and full thickness bites (including endometrium) should be considered. Glove change by the surgical team is recommended after placental delivery and prior to closure of the abdominal wall. The following techniques are not recommended: intra-abdominal irrigation, use of adhesion-prevention barriers, peritoneal closure, and rectus muscle re-approximation. Based on non-cesarean evidence, fascial closure bites should be at least 5 × 5 mm with monofilament suture for vertical incisions. As an adjunct to postoperative pain control, surgeons may consider wound infiltration with local anesthesia either supra- or sub-fascial. Prior to closure, subcutaneous irrigation may be performed with saline, and routine use of subcutaneous drains is not recommended. Though closure of the subcutaneous layer can be considered in all patients, it should occur when the depth is ≥ 2cm. A monofilament absorbable suture, such as poliglecaprone, should be used to close the CD skin incision. There is no level 1 evidence evaluating the potential benefit of additional skin adhesive or sterile strips after suture skin closure. If a dressing is preferred over the skin incision the following may be considered: a DACC-impregnated dressing if available, otherwise a standard gauze dressing is appropriate. Prophylactic negative pressure would therapy can be considered in patients with obesity. Vaginal seeding at CD is not recommended.

BN SO50 - The Resurgence of Veress Needle Insufflation: An Evaluation of Efficacy and Safety of One Surgeon’s Practice

Abstract Background Veress needle insufflation has been established as a safe and effective method of establishing pneumoperitoneum for laparoscopic surgery, with comparable risk profile to open methods. However, the blind nature of the procedure with potential complications such as iatrogenic bowel and blood vessel injury has seen this technique fall out of fashion with general surgeons. This study reviews the safety and efficacy of a single surgeon’s practice using Veress needle insufflation for Laparoscopic surgical procedures. Method A retrospective analysis was conducted on minimally invasive procedures performed between January 2019 and June 2024. In our practice, a standard or bariatric Veress needle is placed in a small incision at Palmer’s point. A manometer test is performed with CO2 insufflation at a low flow rate and raising the abdominal wall. If a low pressure is established, then the flow is increased to achieve adequate pneumoperitoneum before introduction of a midline 5mm camera port. Primary outcomes of this study include rate of conversion to open techniques (either Hasson’s or open cut down) and any complications. Results Of the 702 cases reviewed, five patients (0.71%) required conversion to open insufflation techniques. Two (0.28%) had bleeding from the omentum, and one patient (0.14%) experienced inadvertent bowel insufflation which was managed conservatively with no long-term morbidity. Notably there were no port site hernias. Conclusion This study supports the continued use of the Veress needle as a safe and effective method of insufflation in laparoscopic surgery. It offers minimal incision size, easier access in high BMI patients, and an alternative when adhesions and scarring limit access. Furthermore, adopting this technique can be particularly useful for appropriate port placement in robotic surgery, making it a valuable tool for modern surgical practices.

Case report: Complications after using the “blind-stitch” method in a dairy cow with a left displaced abomasum: treatment, outcome, and economic evaluation

A fourth lactation dairy cow that was 35 days in milk was referred to the clinic for treatment after undergoing unsuccessful treatment of a left displaced abomasum (LDA). The physical examination revealed complications after using the “blind-stitch” method for correction of the LDA; the cow had an abnormal general demeanor, decreased gastrointestinal motility, and local inflammation of the abdominal wall at the site of the suture. Systemic antibiotics, anti-inflammatory drugs, and intravenous fluids were administered, and a right flank laparotomy and omentopexy according to Dirksen were performed after cutting the suture and breaking down the adhesions of the localized peritonitis between the abdominal wall and the abomasal puncture site. The cow was monitored clinically and discharged 2 weeks after referral. The cow was milked for another two lactations producing a total of 18,000 kg of milk, with a lifetime production of 59,141 kg. The total cost for the case was 310 € for the first intervention using the “blind-stitch” method and 897 € for the second laparotomic intervention. The costs (excluding tax) of both procedures including physical examination, surgery, medications, diagnostics, and labor were calculated. The lost revenue associated with the withdrawal period and lower milk production was 4,168 €. Percutaneous LDA fixation techniques, such as the “blind-stitch” and “toggle-pin” methods, have gained popularity because they are quick and cost-effective and involve minimal labor. However, many buiatricians are critical of these techniques because of the high risk of complications. The following four factors require careful consideration when choosing a method for LDA correction: (1) Percutaneous methods require precision and adherence to the described inclusion, exclusion, and cancelation criteria; (2) Operator skill is essential, and therefore regularly performing laparotomies increases surgical experience and enables the veterinarian to better manage different and more complex abdominal disorders; (3) By performing a laparotomy, other underlying abdominal disorders such as reticuloperitonitis and abomasal ulcers may be detected; (4) Postoperative husbandry and treatment are important factors affecting the outcome. The cost calculated for this case underlines the potential benefit and necessity of successful animal health management and the importance of a highly skilled veterinarian and farm workforce.