Complex Abdominal Wall Reconstruction Research Articles

DEVELOPING A ROBOTIC ABDOMINAL WALL RECONSTRUCTION SERVICE IN THE UK – SINGLE CENTRE EXPERIENCE

Abstract Aim A minimally invasive approach (MIS) to complex abdominal wall reconstruction (CAWR) is expanding and offers advantages in enhanced recovery. We report our single-centre experience in the introduction of Robotic CAWR. Methods A retrospective analysis of a prospectively maintained database was carried out from March 2023 to January 2024. All patients undergoing CAWR using a MIS approach were included. Data was collected for the following: sex, age (years), BMI (kg/m2), length of hospital stay (LOS, days), operative time (hours), and post-operative complications. Results 30 patients underwent MIS CAWR (22 robotic; 8 laparoscopic). Male to female ratio was 18:12. The median age was 59 years (IQR 47–66) and BMI 36 kg/m2 (IQR 32–37). Operations included eTEP retro-rectus Rives-Stoppa (RS) + diastasis plication +/- TAR repair using macroporous polypropylene non-absorbable synthetic mesh. Three patients (10%) had TAR and another 3 (10%) had simultaneous inguinal hernia repairs. The median operating time for RS was 3.3 hours (IQR 3.1–3.5) whilst 7.5 hours (IQR 7.2–7.8) for RS + TAR. The median LOS was 2 days (IQR 1–2). Seven (23%) patients developed post-operative urinary retention requiring catheterization. 1 (3%) patient developed a post-operative chest infection. Twenty-two of 27 (82%) patients undergoing MIS Rives Stoppa required oral post-operative analgesia only. 1 (3%) patient had laparoscopic converted to open procedure due to bowel involvement. Conclusion MIS/Robotic CAWR is a safe approach and can be performed in a similar length of time to open procedures. However, LOS is significantly reduced and patients can be successfully managed with oral analgesia.

Anterior versus posterior component separation technique for advanced abdominal wall reconstruction: a proposed algorithm.

The precise indications for employing the anterior component separation technique (ACST) and the Transversus Abdominis Release (TAR) in abdominal wall reconstruction (AWR) remain uncertain, despite the undeniable value of both techniques. The aim of this study was to analyze the anterior fascial closure rate, postoperative wound morbidity, and hernia recurrence rate for both procedures according to the algorithm used for complex AWR. A retrospective analysis of prospectively collected data was carried out. Patients undergoing AWR for midline incisional hernias using either open or endoscopic ACST (E-ACST) or TAR between March 2013 and August 2022 were included. Patients with lateral hernia components were excluded. The surgical technique was depending on the pre- and intraoperative findings regarding hernia width and on the estimated traction to achieve anterior fascial closure (see algorithm). Initially, intermediate hernia defects ranging from approximately 10-14cm in width were repaired using E-ACST. However, as the study advanced, TAR became the preferred method for addressing these types of defects. Open ACST was consistently employed for defects wider than 14-15cm throughout the entire study duration. Outcomes of interest were anterior fascial closure, surgical site occurrences, and hernia recurrence rate. Follow-up was performed at 1month, 1year, and 2years. A total of 119 patients underwent AWR with CST: 63 patients (52.9%) were included in the ACST group and 56 patients (47.1%) in the TAR group. No significant differences were observed in patient and hernia characteristics. The use of botulinum toxin A (BTA) injection and preoperative progressive pneumoperitoneum (PPP) was more frequently used in the ACST group (BTA 19.0%, PPP 15.9% versus BTA 5.4%, PPP 1.8% for TAR patients). Anterior fascial closure was achieved in 95.2% of the ACST group and 98.2% of the TAR group (p = 0.369). The TAR group demonstrated a significantly lower SSO rate at one month (44.3% versus 14.3%, p < 0.001) and required fewer procedural interventions (SSO-PI) (31.1% versus 8.9%, p = 0.003). The recurrence rate at one year was low and there was no statistically significant difference between the two groups (ACST 1.8% vs TAR 4.5%, p = 0.422). Following a proposed algorithm, the anterior fascial closure rate was high and similar for both techniques. As postoperative wound morbidity is significantly increased after ACST, our findings support recommending TAR for defects up to 14cm in width, while favoring open ACST for larger defects.

Postoperative bleeding after complex abdominal wall reconstruction: A post hoc analysis of a randomized clinical trial

BackgroundAbdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction. MethodsAll patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion. ResultsIn 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75–43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34–8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention. ConclusionPatients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk.

Short-term outcomes of minimally invasive techniques in posterior component separation for ventral hernia repair: a systematic review and meta-analysis.

The objective of this study was to perform a systematic review and meta-analysis to summarize various approaches in performing minimally invasive posterior component separation (MIS PCS) and ascertain their safety and short-term outcomes. A systematic literature searches of major databases were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify studies that provided perioperative characteristics and postoperative outcomes of MIS PCS. Primary outcomes for this study were: surgical site events (SSE), surgical site occurrence requiring procedural intervention (SSOPI), and overall complication rates. A random-effect meta-analysis was conducted which allows computation of 95% CIs using simple approximation and incorporates inverse variance method with logit transformation of proportions. There were 14 studies that enrolled 850 participants that were included. The study identified rate of SSE, SSOPI, and overall rate of complications of all MIS TAR modifications to be 13.4%, 5.7%, and 19%, respectively. Our study provides important information on safety and short-term outcomes of MIS PCS. These data can be used as reference when counseling patients, calculating sample size for prospective trials, setting up targets for prospective audit of hernia centers. Standardization of reporting of preoperative characteristics and postoperative outcomes of patients undergoing MIS PCS and strict audit of the procedure through introduction of prospective national and international registries can facilitate improvement of safety of the MIS complex abdominal wall reconstruction, and help in identifying the safest and most cost-effective modification.

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction.

Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes. We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital. We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway. In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Outcomes of complex abdominal wall reconstruction in patients with connective tissue disorders: a single center experience.

Individuals diagnosed with connective tissue disorders (CTD) are known to be predisposed to incisional hernia formation. However, there is a scarcity of data on outcomes for these patients undergoing hernia repair. We sought to describe our outcomes in performing abdominal wall reconstructions in these complex patients. Adult patients with CTD undergoing open, elective, posterior component separation with permanent synthetic mesh at our institution from January 2018 to October 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term hernia recurrence, and patient-reported quality of life. Twelve patients were identified. Connective tissue disorders included Marfan's n = 7 (58.3%), Loeys-Dietz syndrome n = 2 (16.7%), Systemic Lupus Erythematosus n = 2 (16.7%), and Scleroderma n = 1 (8.3%). Prior incisions included three midline laparotomies and nine thoracoabdominal, mean hernia width measured 14cm, and 9 were recurrent hernias. Surgical site occurrences (SSOs) were observed in 25% of cases, and 16.7% necessitated procedural intervention. All twelve patients were available for long-term follow-up, with a mean of 34 (12-62) months. There were no instances of reoperation or mesh excision related to the TAR procedure. One patient developed a recurrence after having his mesh violated for repair of a new visceral aneurysm. Mean HerQLes scores at 1year were 70 and 89 at ≥ 2years; Mean scaled PROMIS scores were 30.7 at 1year and 36.3 at ≥ 2years. Ventral hernia repair with TAR is feasible in patients with connective tissue disorder and can be a suitable alternative in patients with large complex hernias.

Component separation repair of incisional hernia: evolution of practice and review of long-term outcomes in a single center.

To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center. This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients. 89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date. Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.

Loss of domain and reduction in median suture tension

Abdominal wall reconstruction in large incisional hernia/laparostoma poses aparticular challenge. A loss of domain is the extreme form of intestinal volume displacement. The challenge lies in overcoming retraction of the lateral abdominal muscles. Experienced surgeons have access to avariety of techniques aimed at gaining lateral length along the abdominal wall or reducing suture tension at the midline. These techniques are intended to facilitate reconstruction even in complex cases and are outlined in this article from apractical perspective. The application of botulinum toxinA (BTA) and progressive pneumoperitoneum (PPP) are described as preoperative methods to gain abdominal wall length. Peritoneal flaps, intraoperative fascial traction (IFT) and component separation including transversus abdominis muscle release (TAR) are available for the surgical reconstruction of the abdominal wall. Bridging and the intraperitoneal onlay mesh approach are fallback techniques. All these techniques were integrated into apractical algorithm for complex abdominal wall reconstruction including preoperative and postoperative care and assessed by the authors with respect to effort, effectiveness and complexity. In the opinion of the authors, the status of complex abdominal wall reconstruction is currently best described by acombination of the most effective and proven techniques in terms of a"categorical algorithm". The combination of BTA, IFT and TAR presently appears to be the most effective method; however, experience and expertise are aprerequisite.

Preoperative CT imaging as a tool to predict incisional hernia outcomes following abdominal wall reconstruction: A retrospective cohort analysis

Ventral wall hernia often causes significant morbidity and requires complex abdominal wall reconstruction (AWR). This study aims to determine whether subcutaneous abdominal fat thickness (AFT) measured with preoperative CT scans could predict postoperative outcomes in patients undergoing AWR. A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021, with a minimum follow-up of 12 months. Using preoperative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analyzed using statistical tests. The results showed that 9 of 101 patients (8.9%) experienced hernia recurrence. Smoking was associated with an increased risk of hernia recurrence (p<0.001) with a predictive odds ratio (OR) of 18.27 (p=0.041). Increased AFT at the xiphoid (p=0.005), umbilicus (p<0.001), and pubic tubercle (p<0.001) were also associated with hernia recurrence and risk of infection. Only AFT at the pubic tubercle reached significance in the regression model predicting recurrence (OR=1.10; p=0.030) and infection (OR=1.04; p=0.021). A cut-off value of 67mm was associated with a positive predictive value of 42.14% (sensitivity of 67% and specificity of 91%). Hernia defect area was not associated with risk of recurrence or infection. Smoking and increased AFT at the pubic tubercle are significant predictive factors for recurrence and infection in patients undergoing AWR, and preoperative optimization should focus on reducing these factors.

Will Quantifying Fascial Tension Change the Practice of Component Separations in Complex Abdominal Wall Reconstruction?

Will Quantifying Fascial Tension Change the Practice of Component Separations in Complex Abdominal Wall Reconstruction?

Outcomes of Complex Abdominal Wall Reconstruction with Biologic Mesh in Patients with 8 Years of Follow-Up.

While many studies evaluated outcomes of abdominal wall reconstruction with biologic mesh, long-term data is lacking. In this study, we sought to analyze the outcomes of complex AWR with biologic mesh in a robust cohort of patients with a mean follow up of 8years. We conducted a longitudinal study of AWR patients from 2005 to 2019. Hernia recurrence was the primary outcome, and surgical site occurrence was the secondary outcome. Predictive/protective factors were identified using a Cox proportional hazards regression models. We identified 109 consecutive patients who met the inclusion criteria. Patient's mean (± SD) age was 57.5 ± 11.8years, mean body mass index was 30.7 ± 7.2kg/m2, and mean follow-up time was 96.2 ± 15.9months. Fifty-six percent had clean defects, 34% had clean-contaminated defects, and 10% had contaminated/infected defects. Patients had a mean defect size of 261 ± 199.6cm2 and mean mesh size of 391.3 ± 160.2cm2. Nineteen patients (17.4%) developed HR at the final follow-up date. Obesity was independently associated with a four-fold higher risk of HR (hazard ratio, 3.98; 95%CI, 1.34 to 14.60, p = 0.02). SSOs were identified in 24.8% of patients. A prior hernia repair was associated with a three-fold higher risk of SSOs (Odds ratio, 3.13; 95%CI, 1.10 to 8.94, p = 0.03). No patient developed mesh infection. These longitudinal data demonstrate that complex AWR with biologic mesh provides long-term durable outcomes with acceptable HR and SSO rates despite high contamination levels, patients complexity, and large defect size.

181 Lessons Learned from Complex Abdominal Wall Reconstruction for the Management of Giant Paraoesophageal Hernia - a Case Analysis

Abstract Aim In this case report, we present a new method in the management of a giant hiatus hernia: the use of crural relaxing incisions. This new method in combination with previously known strategies including botox and preoperative optimisation for surgery with weight loss and prehabiliation can result in a more effective surgical hiatus hernia repair and subsequently lead to a reduced risk of hiatus hernia recurrence. Case Presentation 71yo man admitted to hospital with a one-week history of generalised abdominal pain, nausea, vomiting and chest pain. He had a background of a known large hiatus hernia for the last 10 years. An abdominal CT showed a large type IV hiatus hernia containing the stomach, transverse colon, pancreatic body, and pancreatic neck. CT guided botulinum toxin A injections were given by interventional radiology during which the muscle bellies of the transversus abdominus, internal and external obliques were targeted. The patient was placed on a meal replacement (Optifast) diet. A laparoscopic thoraco-abdominal hiatus repair was performed finding a giant hiatus hernia containing the entire stomach, first part of the duodenum, left lobe of liver, transverse colon, small bowel and distal pancreas. Due to the size of the hiatus hernia and the potential tension likely to result from a repair, both right and left crural relaxing incisions were made to facilitate closure. Crural closure was reinforced with a Bio A mesh secured in a C configuration covering the right crural relaxing incision. The patient recovered well postoperatively. Follow up imaging did now show recurrence.

WTP5.3 Setting up a Complex Abdominal Wall Reconstruction Unit: Our first 12 months’ experience in a District General Hospital

Abstract Aims Incisional hernias are distressing post-operative complications which develop in 25% of surgical incisions. We present our initial experience of setting up a Complex Abdominal Wall Reconstruction (CAWR) unit in line with international guidelines and Get It Right First Time (GIRFT) model of care. Methods A bespoke CAWR Multidisciplinary Team was established in our trust in January 2022, comprising 2 colorectal surgeons, 2 bariatric surgeons and anaesthetists (who performed the preoperative Botox injections and optimized high-risk patients). The unit had support from radiologists, the weight management service, and the orthotics department. We had approval from our governance, drugs and therapeutics team. Pathways for risk stratification, risk modification with pre-optimisation, standardised surgical techniques and post-operative care were created. Results Between January and December 2022, 8 MDT meetings held and 52 patients were discussed. The average BMI was 34 (22-50.5) All patients underwent a preoperative CT scan to delineate the anatomy of the hernia. The median size of the defect was 6 cm (range 3 to 22 cm). Open Rives-Stoppa repair was performed in 19 patients, with transversus abdominal muscle release in 6 and 3 patients had laparoscopic repair. One recurrence and 2 superficial surgical site infections were noted. 38.4% patients had BOTOX, 40.3% advised preoperative weight loss and 5.7% for bariatric surgery before hernia repair. A high-risk anaesthetic opinion was obtained in for 7.6% and 17% were deemed unfit. Conclusions Our initial experience and data highlight the feasibility of delivery of CAWR service at a non-tertiary unit in line with GIRFT principles. The initial follow-up indicates improved patient outcomes and experience.

625 Complex abdominal wall reconstruction in colorectal cancer abdominal wall metastases - a case report

Abstract Introduction Resection of abdominal wall metastases with curative intent followed by complex abdominal wall reconstruction is seldom performed due to difficulty in ensuring complete resection and need for abdominal reconstruction. It is difficult to successfully localise the boundaries of these metastases for complete excision whilst balancing excessive tissue loss. We present a patient with anterior abdominal wall metastases from colorectal cancer who had this procedure performed successfully at our hospital. Case Presentation This 46-year-old lady originally underwent emergency Hartmans for a perforated sigmoid tumour invading surrounding tissues; pT4pN0R1. She had postoperative chemotherapy, HIPEC/debulking surgery and immunotherapy. A CT scan then suggested disease progression; however, the only active deposits appeared to be in her bilateral recti, so she underwent curative intent surgery - excision of bilateral rectus abdominis metastases, abdominal wall mesh reconstruction, and abdominoplasty. Histology confirmed completely excised colorectal metastatic adenocarcinoma. She did well postoperatively; currently, she continues immunotherapy and works 70 hours/week! Discussion Localisation and R0 resection of rectus metastases is technically challenging; it involves intensive preparation and working closely with the radiological team. The margins of bilateral rectus metastases were localised via immediate pre-operative CT- guided wire placement by an experienced radiologist interacting continuously with the surgeon in the CT room. Conclusion It is possible to safely excise abdominal wall metastases with intensive preoperative planning with the theatre team and radiologists; resultant abdominal wall defects can be repaired appropriately with resultant good quality of life. This procedure should be considered as an option in the management of abdominal wall colorectal metastases with curative intent in selected patients.

Surgeon volumes: preserving appropriate surgical outcomes in higher-risk patient populations undergoing abdominal wall reconstruction.

It is increasingly recognized that complex abdominal wall reconstruction (cAWR) necessitates specialized training. No studies have been conducted to assess whether a volume-outcomes relationship is present in cAWR. We sought to determine if outcomes for patients undergoing cAWR varied based on surgeon volume among participants in the Abdominal Core Health Quality Collaborative (ACHQC). All patients with ventral hernias undergoing elective cAWR with component separation (lateral component release) were selected from ACHQC database. Surgeons were ranked based on annual number of cAWR procedures performed and then grouped in tertiles. Patient characteristics, hernia risk factors, operative details, and 30-days outcomes were evaluated. A total of 9206 patients were identified, of which 310 (3.4%), 723 (7.9%) and 8173 (88.7%) cAWRs were performed by low (105 surgeons), medium (49) and high-volume (66) surgeons, respectively. Patients operated upon by high-volume surgeons tended to have more comorbidities and higher ASA class (72.5% of class ≥ III, vs 53.5%). Hernia characteristics demonstrated that high-volume surgeons more commonly operated on patients presenting with recurrent hernias (50.2% vs 42%), wider hernias (13.5cm vs 10.5cm), associated ostomies (13% vs 3.6%), and prior of surgical site infections (32% vs 26%, P = 0.035). High-volume surgeons more commonly performed posterior component separation procedures (92% vs 84%), utilized permanent mesh (92% vs 88%), and placed mesh in sublay position. In spite of operating on more advanced hernias, high-volume surgeons achieved comparable rates (all P > 0.4) of 30-day surgical site infections (SSI: 6.9% vs 7.1%) and surgical site occurrences requiring procedural intervention (SSO-PI: 8.9% vs 10%). High-volume surgeons maintain comparable outcomes following cAWR despite performing operations on patients with more comorbidities and advanced hernia disease. These findings should be integrated into the debates related to regionalizing abdominal wall reconstruction procedures among high-volume surgeons.

Preoperative Glucose Predicts Postoperative Complications After Complex Abdominal Wall Reconstruction.

Despite advances in surgical methods, complication rates after complex abdominal wall reconstruction (CAWR) remain high. Identification of preoperative risk factors can assist surgeons with risk stratification and patient counseling. The deleterious effects of hyperglycemia on wound healing are well established. With the increasing prevalence of diabetes (diabetes mellitus) and prediabetes, a greater proportion of patients are likely to have increased blood glucose levels that may contribute to poor surgical outcomes. The primary aim of this study was to determine whether preoperative hyperglycemia predicted surgical outcome. The secondary aim was to establish glucose thresholds to assist with surgical risk stratification. All patients who underwent CAWR by the senior author at a single institution from 2002 to 2021 were retrospectively reviewed. Patients were stratified into 4 groups based on preoperative blood glucose: <100 mg/dL (n = 184), 100-140 mg/dL (n = 207), 140-180 mg/dL (n = 41), and >180 mg/dL (n = 16). Patient demographics, risk factors, surgical techniques, complications, and outcomes were recorded and compared. The study cohort comprised of 478 patients. Mean age was 53.9 ± 12.3 years. Mean body mass index was 32.1 ± 7.8 kg/m2. Higher age (P = 0.0085), higher body mass index (P = 0.0005), the presence of diabetes (P < 0.0001), and hypertension (P = 0.0004) were significantly associated with higher glucose. Overall complication rates ranged from 26% (glucose <100 mg/dL) to 94% (glucose >180 mg/dL), whereas recurrence rates ranged from 10% (glucose <100 mg/dL) to 37% (glucose 140-180 mg/dL). Multivariate logistic regression analysis revealed preoperative glucose to have a significant, independent effect on overall complication rate (P < 0.0001), major complication rate (P < 0.0001), and recurrence rate (P < 0.0031). Preoperative hyperglycemia is an important predictor of postoperative complications and recurrence after CAWR. Point-of-care glucose levels are routinely gathered before surgery and may help to establish thresholds for which elective CAWR might be deferred. Strategies to lower preoperative glucose should be part of an optimization protocol for improving outcomes.

One-step totally robotic Hartmann reversal and complex abdominal wall reconstruction with bilateral posterior component separation: a technical note.

This paper describes a robotic approach to combined gastrointestinal continuity restoration and complex abdominal wall reconstruction after Hartmann's procedure complicated by large midline and parastomal hernias. A robotic Hartmann reversal is performed, followed by robotic retromuscular abdominal wall reconstruction of all ventral defects with bilateral posterior component separation using the double-docking approach. Surgical steps are thoroughly described, and the accompanying video highlights critical steps of the procedure, anatomical landmarks and technical details relevant to successful completion. Complete restoration of the anatomy was achieved with an operative time of 6.5 h. Mobilization occured on day 1, and bowels were opened on day 3. Surgical discharge was possible on day 5. No intra-operative surgical complication occurred and follow-up at 6 months showed no recurrence or mid-term complication. Combined minimally invasive reconstruction of the gastrointestinal tract and abdominal wall was feasible using a robotic system. In addition, potential advantages of postoperative rehabilitation and reduced surgical site complications are suggested. Prospective evaluation of the technique is ongoing.

OC-065 THE USE OF CAROLINAS COMFORT SCALE TO COMPARE MESH-RELATED SENSATION BETWEEN BIOSYNTHETIC AND SYNTHETIC MESH: A PILOT STUDY

Abstract Aim Bio-synthetic meshes potentially disappear from the body after certain timeframe leaving behind strengthening scaffold matrix when used for Complex Abdominal Wall Reconstruction (CAWR). We used Carolinas comfort scale (CCS) to assess mesh sensation differences between biosynthetic and synthetic mesh at different time points. Material and Methods This pilot study focusses on patients having undergone CAWR within the unit in the last 3 years. Patients were categorised into four groups of 10 patients each; those repaired with synthetic mesh or biosynthetic mesh within the last 8 months and beyond 18 months. All 40 patients answered all questions of the Carolinas CCS. Decision of mesh type was governed by patient characteristics. Results 10 patients were included in each group (total 40 patients) consecutive retrospective enrolment. We excluded those who had further abdominal surgery or clinical recurrence since. 20 patients repaired with biosynthetic and 20 with synthetic were included. Two-way ANOVA and post HOC Turkey's difference test showed significant difference (p&amp;lt;0.05) in scores in favour of less scores for patients repaired with biosynthetic mesh. This was more pronounced in the beyond 18 month group. Component separation did not make a significant difference in mesh sensation. Logistic Regression analysis revealed patients scored higher on questions related to bending, sitting up and exercise and these were linked. Conclusions This outcome provides a review of current surgical practises and meshes, helping surgeons &amp; patients make better informed decisions. Bio-synthetic meshes have better comfort outcomes for patients with lower CCS scores in the long term.

OC-032 SAFETY OF PERFORMING CONCOMITANT GASTROINTESTINAL RESECTIONAL SURGERY WITH COMPLEX ABDOMINAL WALL RECONSTRUCTION

Abstract Aim The literature regarding combined complex abdominal wall reconstruction (CAWR) and gastrointestinal surgery (GIS) is limited and largely suggests staged procedures due to a reported increased incidence of surgical site occurences (SSO), hernia recurrence and anastomotic leak. However this exposes patients to the risks of two substantial procedures and having general anaesthetic twice. This study aimed to evaluate outcomes of single-stage GIS involving a substantial GI resection with CAWR. Materials &amp; Methods Analysis of a 8 years prospectively maintained single surgeon CAWR database of 205 patients identified 14 such patients who had undergone concomitant CAWR GIS cases (5 segmental colonic resections, 2 completion proctectomies, 5 Hartmann's reversals and 2 small bowel resection and anastomoses) but excluding cholecystectomy, gynaecological surgery and adhesiolysis alone. Results CAWR-GIS mean operating time was significantly longer (5.8hrs vs 3.8hrs) with an increased incidence of post-operative ileus (40% vs 18%, p&amp;lt;0.05) with increased mean length of stay as expected (7.8 days v/s 5.1 days). There was a slightly higher incidence of SSO but there were no anastomotic leaks. Hernia recurrence rate at 2 years follow up was 10% which is comparable to our cohort (8%). None of the 14 patients required reoperation within 30 days or mesh explantation yet. 11 patients had a synthetic mesh and 3 patients had a bio-synthetic mesh used. Patients informally reported high satisfaction for having undergone combined procedures. Conclusion Concomitant intestinal surgery during complex abdominal wall repair can be performed safely without increased risk of hernia recurrence, mesh infections or anastomotic leak.

38. Pre-operative Glucose Predicts Post-operative Complications following Complex Abdominal Wall Reconstruction

PURPOSE: The primary aim of this study was to determine whether preoperative hyperglycemia predicted surgical outcome after complex abdominal wall reconstruction (CAWR). The secondary aim was to establish glucose thresholds to assist with surgical risk stratification. METHODS: All patients that underwent CAWR by the senior author at a single institution from 2002-2021 were retrospectively reviewed. Patients were stratified into four groups based on pre-operative blood glucose: <100 mg/dl (n=184), 100-140 mg/dl (n=207), 140-180 mg/dl (n=41), and > 180 mg/dl (n=16). Patient demographics, risk factors, surgical techniques, complications, and outcomes were recorded and compared. RESULTS: The study cohort was comprised of 478 patients. Mean age was 53.9 ± 12.3 years. Mean body mass index (BMI) was 32.1 ± 7.8. Higher age (p=0.0085), higher BMI (p=0.0005), the presence of diabetes (<0.0001), and hypertension (0.0004) were significantly associated with higher glucose. Overall complication rates ranged from 26% (glucose <100mg/dL) to 94% (glucose >180 mg/dL) while recurrence rates ranged from 10% (glucose <100 mg/dL) to 37% (glucose 140-180 mg/dL). Multivariate logistic regression analysis revealed pre-operative glucose to have a significant, independent effect on overall complication rate (p<0.0001), major complication rate (p<0.0001), and recurrence rate (p<0.0031). CONCLUSION: Pre-operative hyperglycemia is an important predictor of post-operative complications and recurrence following CAWR. Point of care glucose levels are routinely gathered prior to surgery and may help to establish thresholds for which elective CAWR might be deferred. Strategies to lower pre-operative glucose should be part of an optimization protocol for improving outcomes.