Barbed Suture Research Articles

Laparoscopic Hemi-Hysterectomy for Excision of a Functional Rudimentary Uterine Horn Keys to Success

<h3>Study Objective</h3> To present a case of unicornuate uterus with a non-communicating rudimentary horn complicated with hematometra and describe important steps for successful laparoscopic surgical management. <h3>Design</h3> Description of the relevant anatomy and surgical technique with the use of video. <h3>Setting</h3> academic tertiary hospital. <h3>Patients or Participants</h3> A 19-yo female patient with history of dysmenorrhea. Exam revealed normal vagina and cervix deviated to the left, with an adnexal mass on the right. Ultrasound and MRI further delineated a right rudimentary horn with active endometrium, possible hematometra. A renal ultrasound ruled out renal anomaly. Hysteroscopy revealed a normal appearing unicornuate uterus with a tubal ostium. A Rummi manipulatorwas placed. Then, laparoscopic pelvic survey confirmed a left unicornuate uterus with an enlarged right rudimentary horn, no endometriosis was found. Next, ureterolysis was performed, followed by right salpingectomy with ovarian preservation. Vasopressin was injected to the base of the horn (20 units in 100 ml of normal saline). The right utero-ovarian and round ligament were taken down with ligasure device and bladder flap was developed. Next, monopolar L hook was used to resect the rudimentary horn. This was followed by uterine closure in two layers with 2-0 V lock barbed suture. Rudimentary horn was exteriorized in a 10 cm endobag. <h3>Interventions</h3> surgical procedure: diagnostic hysteroscopy, laparoscopic hemihysterectomy for excision of a functional non communicating rudimentary horn. <h3>Measurements and Main Results</h3> Patient was discharged on the same day of the procedure and had an uncomplicated postsurgical course. <h3>Conclusion</h3> Understanding the nature of the uterine anomaly before surgery is of paramount importance for the management of obstructive anomalies of the female genital tract. Laparoscopy is a safe and effective treatment modality to provide pain relief, avoid sequelae, and allow for the preservation of reproductive function.

8387 Instructional Video on Tandem Vaginal Cuff Closure

<h3>Study Objective</h3> To demonstrate the steps of tandem vaginal cuff closure, outline specific movements of the surgeon and assistant, and provide suggestions for efficient closure. <h3>Design</h3> Instructional Video. <h3>Setting</h3> Operating room of large academic hospital. <h3>Patients or Participants</h3> Single patient undergoing a laparoscopic vaginal cuff closure at the time of hysterectomy. <h3>Interventions</h3> In this technique, two surgeons close the vaginal cuff at the time of hysterectomy through an umbilical port for the 5mm camera and two 5mm lateral ports for instrumentation. This eliminates the need for fascial closure and improves cosmesis. The surgeon stands at the patient's left and holds the needle driver in the right hand. The surgeon positions the needle correctly to facilitate an efficient and effective cuff closure starting from the patient's right and proceeding toward the left. The direction of closure is from posterior to anterior. At least 5mm of vaginal mucosa is incorporated into each bite, and uterosacral and cardinal ligaments are incorporated bilaterally to provide support. A key component is to push the needle through the tissue, with over supination of the surgeon's wrist while lifting the needle cephalad. This over-supination allows better visualization and provides the correct angle for needle reloading. The assistant, standing on the patient's right, provides visualization, places the loop of the barbed suture over the needle, and manipulates the anterior or posterior cuff over the needle. <h3>Measurements and Main Results</h3> Complete and efficient vaginal cuff closure with incorporation of uterosacral and cardinal ligaments for support. <h3>Conclusion</h3> With the use of two skilled surgeons, we demonstrate the efficient movements required to carry out a tandem vaginal cuff closure.

Upper Vaginectomy for Rectovaginal Endometriosis: Manual Guidance for Deep Rectovaginal Dissection

<h3>Study Objective</h3> The objective of this video is to demonstrate a robotic-assisted excision of a rectovaginal endometriosis nodule. <h3>Design</h3> This case involves a 31-year-old nulligravid patient with dysmenorrhea, dyschezia, and dyspareunia. <h3>Setting</h3> This surgery was performed at an academic tertiary care center. The patient was in the dorsal lithotomy position and the robot was docked from the patient's left side. <h3>Patients or Participants</h3> The patient had a palpable rectovaginal nodule, which was confirmed with magnetic resonance imaging. <h3>Interventions</h3> The patient underwent diagnostic laparoscopy which showed bilateral pelvic sidewall endometriosis and cul-de-sac obliteration. The ovaries and fallopian tubes were normal. Pelvic sidewall dissection with extensive peritoneal stripping was required to remove all of the endometriosis implants. Bilateral uterosacral ligaments were excised. Within the posterior cul-de-sac, the rectocervical nodule was not visible due to tethering of the rectum. The rectovaginal space was carefully dissected with monopolar scissors. Despite opening the left para-rectal space, the nodule was still not visible. An assistant placed a single digit into the posterior fornix to mobilize the nodule to guide the surgeon. The surgeon dissected the rectovaginal space until the fibrosis was visualized abdominally. Chocolate cyst fluid was expelled, consistent with deep infiltrating endometriosis. Full-thickness entry into the vagina was required, and the colpotomy was closed with running barbed suture. After complete excision of endometriosis, a flat-tire test was performed to confirm rectal integrity. The surgery was then completed. <h3>Measurements and Main Results</h3> The patient did well and was discharged home from the recovery room. She had significant improvement in her pain, and her recovery proceeded without complications. <h3>Conclusion</h3> This surgical video demonstrates the importance of careful pre-operative planning and intra-operative use of resources to accomplish complete excision of endometriosis. Surgeons often need to be creative when tissue planes are obscured, and the target pathology is not clearly visible.

Vasopressin Injection Purse-String Ectopic Resection (VIPER) Technique for Laparoscopic Management of Cornual Ectopic

<h3>Study Objective</h3> To describe the VIPER technique for the laparoscopic management of cornual ectopic pregnancy; a technique that minimizes blood loss and mitigates risk of conversion to laparotomy. <h3>Design</h3> Case series. <h3>Setting</h3> High-volume, academic and academic-affiliated medical centers. <h3>Patients or Participants</h3> All patients presenting with cornual ectopic pregnancy managed surgically. <h3>Interventions</h3> Laparoscopic cornual resection by five Minimally Invasive Gynecologic Surgeons. The VIPER technique utilizes four ports (umbilical, left lower quadrant, and ipsilateral right sided) and a 30-degree laparoscope. After obtaining visualization, dilute vasopressin is injected into the myometrium adjacent to the pregnancy. The affected fallopian tube is disconnected distally. A purse-string stitch with uni-directional barbed suture is placed circumferentially around the pregnancy and cinched. This stitch achieves hemostasis regardless of rupture status. The needle is left attached, and a wedge resection of the cornua is performed with an ultrasonic device. The myometrial defect is repaired with the remaining suture. <h3>Measurements and Main Results</h3> 17 patients underwent laparoscopic cornuectomy between 2012 to 2022, with 7 found to be ruptured. The mean patient age was 30 years (range 20-41), mean body mass index was 31.4kg/m² (range 22-52), and mean gestational age was 8 weeks 6 days (range 5 weeks 6 days to 11 weeks 1 day). Patient risk factors included history of prior sexually transmitted infection (3 patients), in vitro fertilization (1 patient), and prior ectopic pregnancy (1 patient). The other twelve patients had no risk factors. The mean operative time was 107 minutes (range 50-229), with mean estimated blood loss of 41mL for non-ruptured and 412mL for ruptured ectopic pregnancies. The mean hemoperitoneum identified was 1117mL, (range 50mL to 3325mL). There were no conversions to laparotomy. 70.6% of patients were discharged on the day of surgery. <h3>Conclusion</h3> The VIPER technique is feasible and effective for the management of both non-ruptured and ruptured cornual ectopic pregnancy.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation

<h3>Study Objective</h3> Discuss advantages of ethylene vinyl alcohol copolymer (EVAC) use for uterine arterio-venous malformation (AVM). Demonstrate technique for vascular control during robotic repair of isthmocele. <h3>Design</h3> Video documentation of the surgical procedure (instructive video). <h3>Setting</h3> University of California, San Francisco Hospital operating room with patient placed in dorsal lithotomy positioning. <h3>Patients or Participants</h3> A 37-year-old woman, status-post embolization of uterine AVM, presenting with a 3.5 × 2.5 cm uterine isthmocele. <h3>Interventions</h3> Discuss embolization of a uterine AVM. Then, present a case of AVM with isthmocele, review the patient's imaging, and show a stepwise approach to the procedure. Hysteroscopy is performed to identify the isthmocele location and visualize the cavity post-embolization. The robotic platform was chosen as the mode of surgery. Entry into the retroperitoneum with transient occlusion of the uterine arteries is planned due to proximity of isthmocele to left uterine artery as seen on MRI. Once the pararectal space is entered the ureter is localized on the medial leaf of the broad ligament. The uterine artery is then isolated and skeletonized. This procedure is performed bilaterally. Vascular clamps are then placed on the uterine arteries at their respective origins. The bladder is also backfilled to aid in creation of a bladder flap given the history of c-section. With firefly technology, the borders of the isthmocele are identified. This area is resected, the residual copolymer is removed from the defect, and the hysterotomy is repaired in two layers using unidirectional barbed suture. At the conclusion of the case, the vascular clamps are removed and vascular supply is restored. <h3>Measurements and Main Results</h3> Isthmocele resection and repair was achieved with an estimated blood loss of 25mL. The patient's symptoms resolved. <h3>Conclusion</h3> Evaluation of pathology on pre-operative imaging can impact surgical approach. Transient occlusion of the uterine arteries can aid in repair of isthmocele with minimal blood loss.

8407 Interstitial Ectopic Pregnancy: A Case Series with Practical Tips for Surgical Management

<h3>Study Objective</h3> To review current treatment options for interstitial ectopic pregnancy (IP), with a focus on surgical treatments. To review outcomes of three surgically managed cases of IP. To demonstrate practical tips for success in laparoscopic management of IP. <h3>Design</h3> A case series presenting three cases of surgically managed IP with guided explanation of surgical intervention using video. <h3>Setting</h3> Academic affiliated community hospital. <h3>Patients or Participants</h3> The 3 cases of IP evaluated and treated over the past year were included in the study. <h3>Interventions</h3> Two patients underwent laparoscopic cornual resection of IP and one patient underwent emergent abdominal repair of ruptured IP. <h3>Measurements and Main Results</h3> Estimated blood loss (EBL) for laparoscopic management of 6-week IP with preoperative uterine artery embolization (UAE) was 20ml; length of post operative length of stay (LOS) was 1 day. EBL for 13-week IP without embolization was 50 ml, post op LOS was 0 days. EBL for ruptured IP repaired via open approach was 1000ml including hemoperitoneum, post operative LOS was 2 days. Beta hCG was trended once per week post operatively for all patients. Both patients undergoing laparoscopic resection had negative HCG by week 4. The patient with ruptured IP had negative hCG by week 8; however, she did not complete testing between week 5-7; at 4 weeks her hCG was 17. <h3>Conclusion</h3> IP is sometimes a difficult diagnosis to make; a high index of suspicion is necessary. Laparoscopic surgery for IP is achievable using similar techniques as laparoscopic myomectomy for limiting perioperative blood loss and repair of the myometrial defect; Ultrasonic scalpel, vasopressin, delayed absorbable barbed suture. IP can often be treated laparoscopically, however laparotomy may be necessary in unstable patients with advanced gestation. Further investigation is necessary to determine the best practice for surgical management of IP.

Management of Vaginal Vault Dehiscence after Laparoscopic Hysterectomy

<h3>Study Objective</h3> To review the epidemiology, diagnosis and management of vaginal vault dehiscence, and to illustrate a 5-step surgical approach to laparoscopic vault repair. <h3>Design</h3> Surgical footage was obtained from an emergency case after appropriate consent from the patient. <h3>Setting</h3> A tertiary care centre. <h3>Patients or Participants</h3> A 34-year-old female who presented 8 weeks after a total laparoscopic hysterectomy with a complete vault dehiscence. <h3>Interventions</h3> Vaginal vault dehiscence complicates 0.64% to 1.35% of laparoscopic hysterectomies, and can be categorized as complete cuff dehiscence, partial cuff dehiscence or partial thickness. Protective factors include the use of barbed sutures as compared to non-barbed sutures and laparoscopic closure as compared as compared to vaginal closure. Smoking and low BMI have been associated with an increased risk of dehiscence. <h3>Measurements and Main Results</h3> The surgical approach to a laparoscopic repair of cuff dehiscence can be standardized in 5 reproducible steps: abdominal survey, bladder and/or rectal dissection, vault debridement, vault closure and cystoscopy. <h3>Conclusion</h3> Vaginal vault dehiscence being uncommon, residents may graduate without being exposed to a case. This video represents an educational tool that covers the clinical and surgical approaches to the reproducible management of vaginal vault dehiscence.

Robotic-Assisted Laparoscopic Treatment of Diaphragmatic Endometriosis

<h3>Study Objective</h3> To demonstrate the surgical technique used for a robotic-assisted diaphragm endometriosis treatment. <h3>Design</h3> Case report illustrated with a video. <h3>Setting</h3> Patient is placed in the semi-gynecological position, left lateral decubitus and proclivity. Robotic side docking set for upper abdomen using da Vinci Si platform. <h3>Patients or Participants</h3> A 34-year-old woman reports dysmenorrhea and pain in her right shoulder during menstruation for 5 years, ceased after combined oral contraceptive use. When she stopped the contraceptive, symptoms recurred. On MRI, hematic foci were identified in the right subphrenic space, suggesting endometrial implants. <h3>Interventions</h3> A 12 mm incision is performed in the umbilicus for endoscope port. Other two 8mm robotic ports and a 5 mm accessory laparoscopic trocar were placed. Patient's cart side docking enters obliquely through patient's left shoulder. Inspection shows superficial and deep typical endometriotic lesions on right diaphragmatic surface, falciform ligament is sectioned for better liver mobilization. Most superficial lesions are removed before accessing thoracic cavity. For deeper lesions, the diaphragm is opened, showing pleural involvement of endometriosis. No pulmonary lesions were identified. Diaphragm is repaired carried out by a double-layered barbed suture. Before first layer closure, a laparoscopic suction tip is introduced into the thoracic cavity and the aspiration of the pneumothorax is done concomitantly with the forced Valsalva maneuver. <h3>Measurements and Main Results</h3> Patient was discharged in the second postoperative day, showing great evolution in respiratory physical therapy and normal chest X-ray. Painful shoulder symptoms have completely resolved. <h3>Conclusion</h3> Diaphragm endometriosis has been gaining more attention in the practice of gynecologist surgeons. Robotic system improves access to the subdiaphragmatic space due to the articulated instrument movements and 3D high-definition static vision. Excision of diaphragmatic lesions is a standardized feasible procedure that allows complete treatment and good clinical results.

Incarcerated Small Bowel inside A Slide Hernia Composed of Colon Wall Triggered by Left Bochdalek Hernia in Adult:An Extremely Rare Etiology of Acute Intestinal Volvulus

Acute abdomen triggered by acute bowel obstruction is common in clinical practice, which may be caused by various reasons such as inflammation, tumors, intussusception and incarcerated hernia,etc. Here by, we describe a young man who was a heavy phsical worker presented with an abdominal pain and a sudden onset for nearly a day duration, accompanied with frequent nausea and vomiting, which could be partially relieved on his standing position. Empty feeling with mild tenderness was palpable on his right lower quadrant abdomen and abnormal bowel sounds were heard in his left chest cavity. Acute abdominal intestinal incarcerated obstruction was demonstrated on computed tomography (CT) of the abdomen. Urgent laparascopic exploration unveiled a Bochdalek hernia with a 3 cm defect in diameter that was subsequently closed by continual suture after the incarcerated reduced. The key to success is early identification of characterized features on images such as chest X-ray and abdominal CT, combined with the abdominal pain attack relieved by standing or semi-recombent position. In addition, the defect of Bodalek hernia is recommended to take a continual suture with a slowly absorbed barbed suture so as to strenthen the firmeness of the diaphragm.

Effect of barbed suture versus conventional suture in laparo-endoscopic single-site cystectomy for ovarian mature cystic teratoma: An ambispective cohort study.

To compare the effects of barbed suture (BS) and conventional suture (CS) on perioperative conditions and ovarian function in the excision of ovarian mature cystic teratoma (MCT) by laparo-endoscopic single-site surgery (LESS). The present study is an ambispective cohort study conducted in an affiliated tertiary hospital between May 2019 and October 2020. Women treated by LESS cystectomy for unilateral ovarian MCT were included. BS or CS were applied in the surgery. BS and CS groups were matched 1:1 for age, body mass index and ovarian cyst volume (40 women per group). There were no significant differences in baseline characteristics. Mean operating time (53.89 ± 14.80 versuss 67.93 ± 19.23 min, P=0.004) and suturing time (11.85 ± 6.68 versus 19.76 ± 12.75 min, P=0.006) were significantly shorter in the BS group than the CS group. No significant differences were found in serum anti-Müllerian hormone (AMH) levels between groups at baseline, postoperative day 1, 3months, and 12 months. However, serum AMH was significantly lower than baseline at postoperative day 1, 3months, and 12 months in both groups. BS provides shorter operating and suturing time than CS, without increasing damage to ovarian function in LESS cystectomy for ovarian MCT.

V-029 TOTALLY ENDOSCOPIC SUBLAY (TES) REPAIR FOR L2-L3 INCISIONAL HERNIA

Abstract Aim Endoscopic lateral incisional hernia (IH) repair provides advantages in terms of low infection rates and hospital stay when compared with open repair. Material and Methods 62 years old men with a history of HTA and an open radical right nephrectomy for a renal tumor, developed a symptomatic iliac IH. L2–3 W2 according to the European Hernia Society (EHS) classification was clinically diagnosed and confirmed with a CT scan. Full endoscopic abdominal wall repair with defect closure was proposed. 3 trocars in right retrorectus space were placed. Once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, access to the preperitoneal lateral plane. During hernia sac dissection, an opening of the hernia sac occurs. The posterior layer is closed by a barbed suture, an accessory trocar placement was necessary for the closure. Subsequently, the internal oblique and transversus abdominis muscles that formed the defect were approximated with a barbed suture. During dissection, a right inguinal hernia was identified and repaired. A trimmed 20 x15 cm polipropilene mesh is placed in the preperitoneal space without fixation. Results The patient was discharged on the 3rd postoperative day without complications. Follow-up in the outpatient clinic at 6 months did not show any signs of recurrence. Conclusion Endoscopic abdominal wall reconstruction with posterior component separation is an alternative to the open procedure for lateral IH, providing a complete abdominal wall repair. The mesh is placed extraperitoneal with the advantages in terms of less adhesions and postoperative pain.

P-150 TRANSVERSUS ABDOMINIS RELEASE BY MINIMAL INVASIVE SURGERY. OUR EXPERIENCE IN A TERCIARY HOSPITAL

Abstract Aim We present the experience in the transversus abdominis release (TAR) technique using a minimally invasive approach in our center. Methods We expose those W3 defects intervened by laparoscopic TAR(n=6). Step 1: Releasing adhesions from previous surgeries. Step 2: Bilateral Rives space dissection, as well as the Rossen's space, this one using “down to up” technique. Step 3: Closure of the gap with barbed suture. In all cases, a PVDF mesh has been associated with atraumatic fixation, and 2 drains were placed. Results The mean age was 62, 100% men, and their BMI was greater than 25Kg/m2. All underwent scheduled surgery, using a minimally invasive approach, placing the mesh at the retromuscular level. Postoperative stay was 7.6 days. We did not obtain major complications (perforation, bleeding), but a drainage hole wound infection was registered. We had no readmissions or any medical complications. Follow-up of 12 months, without signs of recurrence or chronic pain. Conclusions Although Robotic surgery and Botulinum toxin in surgery seems to be the future, in our experience TAR technique performed by laparoscopy is useful for large midline incisional hernias treatment as well as those associated with a lateral component in a terciary Hospital. We obtain good results in terms of recurrence and restoration of the abdominal wall dynamics. However, further studies are necessary to be carried out by experienced teams to reach conclusions.

V-027 2-IN1: LAPAROSCOPIC TAPP REPAIR OF CONCURRENT SPIGELIAN AND INGUINAL HERNIAS

Abstract Aim Spigelian hernias are rare hernias of the abdominal wall and difficult to diagnose clinically. Our aim is to report a diagnostic and surgical challenge of the combination of inguinal and Spigelian hernias. Material &amp; Methods 74 year old female presented with pain in right inguinal region and lump in right iliac fossa. The ultrasound scan revealed right sided Spigelian hernia up to 4 cm, right inguinal hernia up to 1 cm and incidentally detected contralateral Spigelian hernia up to 3 cm on the left side. Results Laparoscopic transabdominal preperitoneal (TAPP) hernia repair was performed of both right Spigelian and ipsilateral inguinal hernias. The hernia sacs were dissected and 25×15 cm polypropylene mesh was placed, covering both hernia sites. The mesh was fixed using absorbable tacks. The peritoneum was closed using barbed suture. The repair of contralateral Spigelian hernia was planned as a second stage procedure due to the present comorbidities. Operation time was 140 min. The patient was discharged on the next postoperative day. Ultrasound scan performed after 3 weeks did not show any signs of seroma, hematoma or recurrence. Conclusions An accurate preoperative diagnosis of Spigelian and inguinal hernias led to the safe and successful laparoscopic repair with preperitoneal mesh placement.

P-142 CLINICAL AND ECONOMIC OUTCOMES OF ABSORBABLE KNOTLESS BARBED SUTURE VERSUS OTHER CONVENTIONAL SUTURES FOR ABDOMINAL MIDLINE CLOSURE IN PATIENTS UNDERGOING OPEN HERNIA REPAIRS

Abstract Aim We assessed clinical and economic outcomes of patients undergoing open hernia repair using absorbable knotless barbed suture versus conventional absorbable suture for abdominal wall closure. Methods This retrospective cohort study identified patients undergoing hernia repair at a single center between 2013 and 2020. Fixed follow-up of 30, 60, and 90 days were used to assess outcomes (peri-operative complications, and resource utilization). Multivariate analyses for outcomes and Cox Proportional Hazards models for time to readmission and complications were conducted. Results Of 821 hernia repairs, 446 used absorbable knotless barbed suture and 375 used conventional absorbable suture. Baseline characteristics were largely similar between the groups. Surgical site infections (SSI) were significantly less frequent with absorbable knotless barbed suture (60-day, 5.9% vs. 11.4%; P=0.0083; 90-day, 5.9% vs. 11.7%; P=0.006) and remained consistent after multivariate adjustment (60-day, OR [95% CI]: 0.52 [0.29–0.92]; 90-day, 0.51 [0.28–0.90]). Among patients with SSI, deep SSI were less frequent with absorbable knotless barbed suture (60-day, 9.1% vs. 35.7%; P=0.022; 90-day, 9.1% vs. 34.9%; P=0.0252). Absorbable knotless barbed suture significantly reduced the risk of peri-operative complications over time (HR 0.57 [95% CI 0.36–0.92]; P=0.0203). Hospital length of stay was, on average, 2.74 days longer in conventional absorbable suture patients (mean [95% CI] 8.75 [7.83–9.78] vs. 6.01 [5.16–6.99] days; P&amp;lt;.0001). Conclusions Significant differences between sutures were seen with peri-operative infections, which occurred less frequently with absorbable knotless barbed suture and less severe. Peri-operative complications and length of stay were significantly reduced with absorbable knotless barbed suture.

OC-078 LAP-T LAPAROSCOPIC GAS-LESS TECHNIQUE FOR THE REPAIR OF RECTUS MUSCLES DIASTASIS AND HERNIA IN ATHLETES

Abstract Background/Aim Diastasis of Rectus Abdominis Muscles (DRAM) in athletes is typically associated with muscle and fascial tearing and fracture and umbilical/epigastric hernias. Parietal damage is generally located on midline, subjected to continuous efforts and overload. Contrarily to repair of DRAM consequent to pregnancy or obesity, in athletes, the trigger of injury will persist after repair. LAP-T Technique aims at Mini-Invasive restoration of anatomy and physiologic functionality through laparoscopic tailored suture&amp;mesh repair, allowing return to full sport activity. Methods 96 cases from January 2010 to May 2021, minimum follow-up of 12 months. Elected patients: athletes, under 60 years old, BMI &amp;lt; 30, ASA1 – ASA2, with maximum IRD 10cm and associated AWR. Rectus muscles are re-approximated from xiphoid to pubis with tailored sutures, and hernia defect repaired, using laparoscopic running self-locking barbed sutures. Entire procedure is performed in gas-less laparoscopy (3mmHg). Considering persistence of triggering cause after repair in athletes, the repair is consolidated placing an intra-peritoneal mesh. 10–15 days from surgery, patients start following a tailored rehabilitation program up to full resumption of sport activity. Results In all patients, AW anatomy and physiological functionality were successfully restored, any hernia repaired, with the restitution ad integrum of the AW; no higher pain related to the continuous suturing has been reported compared to bridge IPOM laparoscopic repair, while allowing for physiologic outcome and stronger repair. No intra operative bleeding, no seroma formation, chronic pain, nor mesh infection. All athletes retrieved full sport activity at pre-hernia and DRAM level. 98% follow up at 12 months, 91% at 24, with no recurrences observed. Conclusions LAP-T technique proved to be feasible technique for Athletes, allowing for sound and anatomic reconstruction of DRAM, associated hernias, and musculo-fascial tearing, with reduced trauma, fast recovery and full resumption of sport activity.

V-033 LATERAL INCISIONAL HERNIA. IPSILATERAL ENDOSCOPIC TRANSVERSUS ABDOMINAL RELEASE AND PREPERITONEAL REPAIR

Abstract We present the clinical case of a 58 year old patient with a left subcostal incisional hernia, years after an emergent aortic thrombectomy and aortobifemoral bypass. The physical examination revealed a lateral subcostal bulge near the anterior axillary line. CT findings showed a left lateral 5 cm defect without significant muscular atrophy. An endoscopic ipsilateral transversus abdominal release (TAR) and preperitoneal mesh repair was successfully performed. 1: Port placement. We used one 10 mm port and two 5 mm ports in a left near-midline position. 2: Retrorectal and Bogros space dissection. Locating the arcuate line and opening the posterior rectus sheath we then proceeded with the left transversus abdominal release (in a down to up direction). 3: Hernia dissection. After the hernial sac is identified we opened it to explore the peritoneal cavity and release the possible adhesions if encountered. 4: Full space dissection. Once the defect dissection is finished, we fully completed the TAR in order to achieve a satisfactory space for the mesh placement. 5: Defect closure. We performed a two-plane resorbable continuous barbed suture. 6: Mesh placement. We measured the surgical space in order to insert a tailored mesh and lay it without fixation or drain. Clinical outcome: The patient is discharged on postoperative day 1 and took acetaminophen 3 times daily for 48 hours, due to good pain control. On the first postoperative followup (10 days) the patient had resumed usual activities, driving and was already back to work. He was advised to avoid heavy efforts.

V-016 PARAHIATAL HERNIA: A RARE CASE OF DIAPHRAGMATIC HERNIA ROBOTICALLY REPAIRED

Abstract Aim Parahiatal hernia is a rare type of diaphragmatic hernia, consisting in a adjacent but separated defect, lateral to the oesophageal hiatus and crus. It's not so familiar for surgeons, preoperative diagnosis is unlikely to be confirmed, and it is mostly found incidentally during intervention, leading to a complex and difficult repair. We present a case of parahiatal hernia robotically treated with the aim of emphasizing how robotic system can successfully help surgeons in performing even unexpected confusing and challenging anatomic dissections and procedures. Material and Methods A 65-year-old woman underwent robotic parahiatal hernia repair at our Institution. Four robotic trocars were positioned along the transverse umbilical line with the additional Air-seal port at the periumbilical left side for assistant's use. Dissection and isolation of both parahiatal defect and crural musculature were performed; the defect was closed with not absorbable barbed suture, conventional iatoplasty was also performed and a biosynthetic mesh was placed and fixed as a reinforcement. Results The duration of the intervention was of 100 minutes. No. intr- or post-operative complications occurred. Blood loss were inferior than 100 millilitres. The patient started oral intake at the second post-operative day and after discharged. At six months no recurrences were detected. Conclusions Parahiatal hernia are rare entities of which surgeons should be aware. Robotic treatment is safe and feasible and it represents a good tool for a successful management.

P-107 DOES BARBED SUTURE REDUCE THE RATE OF EVISCERATIONS IN EMERGENCY MIDLINE LAPAROTOMIES?

Abstract Introduction Evisceration is a frequent consequence after performing midline laparotomies (ML) in urgent abdominal surgeries. The aim of this study was to compare and evaluate the results obtained after the introduction of barbed sutures in abdominal wall closure. Materials and methods We performed a retrospective analysis of patients undergoing emergency surgery in our hospital following a midline laparotomy approach in the last 5 years. Preoperative variables were compared between both groups and related to early surgical wound complications, depending on the type of abdominal wall closure performed. Results 222 patients underwent surgery (Polydioxanone (P); 128; Barbed (B); 94) after ruling out exclusion factors such as neuromuscular disease, recent abdominal surgeries and whose follow-up had been lost. There were no significant differences between the two groups in terms of preoperative baseline characteristics or associated comorbidities. Furthermore, there were no statistically significant differences in type of surgery performed; the most frequent was small bowel obstruction. After data analysis, no differences were found in terms of hospital stay (P; 7.43 days vs B; 6.05 days, p=0.421) or mortality (P; 3.125% vs B; 4.25, p=0.655). Concerning immediate complications, there were no differences regarding surgical wound infection (P; 18.75% vs B; 10.63%, p=0.061) and seroma (P; 3.125% vs B; 2.12, p=0.651). Evisceration rates turned out to be more frequent in the polydioxanone group (P; 20.31% vs B; 8.51%, p=0.016). Conclusions The use of barbed sutures reduced the incidence of evisceration, therefore it can be considered as recommended sutures for aponeurotic closure in emergent ML.

V-010 LAPAROSCOPIC TAPP APPROACH OF A GRYNFELLT HERNIA

Abstract Aim To describe our laparoscopic transabdominal preperitoneal approach of a Grynfellt hernia. Material &amp; Methods A female patient 69 years of age with no previous medical history came to our consultation with a chronic right lumbar bulge that produced local pain and discomfort. Preoperative CT scan showed a primary lumbar hernia with a defect estimated at 11cm. Laparoscopic approach seemed feasible and was accepted. Results The patient was placed on a left decubitus with the OR bed at a 45° angle. 3 trocars were used, one slightly lateral of the umbilicus for the camera, and for triangulation a subcostal 5mm and an 11mm trocar in the left flank. We started opening the peritoneum and performing preperitoneal space dissection. The hernia sac was identified and its contents were reduced. We closed the defect using a monofilament absorbable barbed suture with a running stitch. Once the defect was closed, we placed a medium-weight polypropylene mesh in a 3D “taco” configuration covering the defect with sufficient overlap. Both the mesh and the peritoneum closure were done using cyanoacrylate glue. No complications occurred and discharge was the next day. Conclusions Primary lumbar hernias are rare. Symptomatic hernias should be treated as they can lead to pain, discomfort, and a decrease in quality of life. Laparoscopic TAPP is a safe and simple way to access and repair these hernias, allowing an adequate space of dissection that permits the placement of a mesh tension-free with sufficient overlap, with a quick recovery time and minimal morbidity.

Enterotomy Closure after Minimally Invasive Distal Gastrectomy with Intracorporeal Anastomosis: A Multicentric Study

Introduction: Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis. Methods: All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread. Results: Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029). Conclusions: Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.