European Hernia Society Classification Research Articles

Evaluating EHS parastomal hernia classification for surgical planning: a retrospective analysis of 160 consecutive cases in a single center.

Parastomal hernia (PH) is a prevalent complication following ostomy formation, presenting significant challenges in surgical management. This study aims to validate the European Hernia Society classification for PH through the application of the Hybrid Parastomal Endoscopic Repair (HyPER) method. The study focuses on establishing the practical utility of the European Hernia Society classification in a clinical setting, particularly in guiding surgical approaches and improving patient outcomes. This retrospective observational study aimed to assess the utility of the European Hernia Society classification in planning surgical strategies for parastomal hernias. The validation of the classification of PH was based on the experience involving 160 patients in single center. Patients were classified according to the European Hernia Society criteria, and data were collected on patient demographics, clinical presentations, and surgical outcomes. Main goal was to assess the consistency and applicability of the European Hernia Society classification in predicting surgical challenges and outcomes. The study found a predominance of complex Type III and IV hernias. The European Hernia Society classification was effective in categorizing PH, aiding in surgical planning and highlighting the increased complication rates associated with more complex hernia types. This study represents the largest single-center cohort treated for PH by a single team, providing a controlled evaluation of the HyPER technique's effectiveness. The validation of the European Hernia Society classification in this study is a significant advancement in the standardization of PH management. The findings demonstrate the classification's utility in enhancing surgical planning and patient-centered care. The study also opens avenues for further research into standardized approaches and techniques in PH treatment.

Cord lipoma in minimally invasive surgical repairs of inguinal hernias: a prospective study.

Cord lipomas are frequent findings in laparoscopic inguinal hernia surgeries in male patients. The symptoms of lipoma and the potential benefits of removing them are often overlooked because the focus is on the primary pathology of the hernia itself. Current recommendations are to reduce this fatty content, when present. When inguinal cord lipomas are left untreated in inguinal hernia surgery they can potentially cause symptoms and be detected in follow-up imaging exams. The objective of this study was to study incidence of cord lipomas in a cohort operated on by a single group specializing in abdominal wall surgery, as well as to analyze the possible relationship of this finding with the patient's symptoms, the characteristics of the operated hernia and postoperative outcome. This is a prospective study of male patients operated on for inguinal hernia laparoscopically or robotically in a single reference center. Of the total of 141 hernias, the distribution according to European Hernia Society classification showed that 45.4% were lateral, 19.1% medial and 35.5% mixed, highlighting a variety in the presentation of hernias. Analysis of the size of the hernias revealed that the majority (35.5%) were ≤ 1.5cm. Inguinal cord lipoma was present in 64.5% of the samples, with no statistically significant association between the presence of the lipoma and an indirect hernia sac or obesity. The incidence of surgical site occurrences (SSO) was 9,2%, with seroma and hematoma. No recurrences were observed during follow-up, indicating a successful approach. There were no statistically significant relationships between SSO, the presence of lipoma and indirect hernial sac.

Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release

Posterior components separation (PCS) is a commonly used myofascial release technique in ventral hernia repairs. The contribution of each release with anterior and posterior fascial advancement has not yet been characterized in patients with ventral hernias. To quantitatively assess the changes in tension on the anterior and posterior fascial elements of the abdominal wall during PCS to inform surgeons regarding the technical contribution of each step with those changes, which may help to guide intraoperative decision-making. This case series enrolled patients from December 2, 2021, to August 2, 2022, and was conducted at the Cleveland Clinic Center for Abdominal Core Health. The participants included adult patients with European Hernia Society classification M1 to M5 ventral hernias undergoing abdominal wall reconstruction with PCS. A proprietary, sterilizable tensiometer measured the force needed to bring the fascial edge of the abdominal wall to the midline after each step of a PCS (retrorectus dissection, division of the posterior lamella of the internal oblique aponeurosis, and transversus abdominis muscle release [TAR]). The primary study outcome was the percentage change in tension on the anterior and posterior fascia associated with each step of PCS with TAR. The study included 100 patients (median [IQR] age, 60 [54-68] years; 52 [52%] male). The median (IQR) hernia width was 13.0 (10.0-15.2) cm. After complete PCS, the mean (SD) percentage changes in tension on the anterior and posterior fascia were -53.27% (0.53%) and -98.47% (0.08%), respectively. Of the total change in anterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -82.56% (0.68%), incision of the posterior lamella of the internal oblique with a change of -17.67% (0.41%), and TAR with no change. Of the total change in posterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -3.04% (2.42%), incision of the posterior lamella of the internal oblique with a change of -58.78% (0.39%), and TAR with a change of -38.17% (0.39%). In this case series, retrorectus dissection but not TAR was associated with reduced tension on the anterior fascia, suggesting that it should be performed if anterior fascial advancement is needed. Dividing the posterior lamella of the internal oblique aponeurosis and TAR was associated with reduced tension on the posterior fascia, suggesting that it should be performed for posterior fascial advancement.

V-004 ROBOTIC PARASTOMAL HERNIA REPAIR WITH RETROMUSCULAR MESH (PAULI TECHNIQUE)

Abstract Aim Parastomal hernia is a common complication of ostomy formation. We present a case of robotic parastomal hernia repair with retromuscular mesh (Pauli technique). Material and Methods Patient was 58 years-old man and had history of anterior resection of the rectum, terminal colostomy and onlay mesh parastomal hernia repair. After 2 months of parastomal hernia repair, the patient developed a recurrence (type III, European Hernia Society Classification). Results Robotic parastomal hernia repair was performed with transabdominal approach. Firstly, a small adhesiolysis of the colon to the stoma orifice was made. Then, the peritoneum and posterior sheath of the left rectus muscle was incised. The retrorectal space was dissected. The hernia sac was incised circumferentially. TAR dissection was launched lateral to the stoma. After the development of the landing zone for the mesh, the posterior retromuscular fascia was incised lateral to the stoma. The inner orifice of stoma was repositioned. A large-pore polypropylene mesh (20×28 cm) was placed in the retromuscular space and fixed it, lateral to the ostomy orifice. Finally, the retromuscular pocket was closed by suturing the posterior fascia to the linea alba. The patient was discharged on postoperative day 4 and had no complications. After 4 months of follow-up, no hernia recurrence had been recorded. Conclusions Robotic Pauli is a technique to repair parastomal hernias that provides wide coverage of the defect and avoids leaving mesh intraperitoneally. They could provide a secure repair and prevent postoperative complications (pain or intestinal ileus). It is technically challenging but feasible.

OC-006 INTRAOPERATIVE FASCIA TRACTION FOR THE TREATMENT OF LARGE ABDOMINAL WALL/INCISIONAL HERNIAS (W3, EHS)

Abstract Aim To evaluate the effectiveness, clinical practicability, and complication rate of the fascial traction procedure for the treatment of large ventral hernias. Method This observational study evaluated 90 patients from 1 specialised center with an intraoperatively measured fascial distance of more than 10 cm who were treated by Intraoperative Fascia Traction – IFT- (abdominal wall stretching) using the fasciotens® hernia traction procedure. Results Fascial gap measured pre-operatively ranged from 10 to 44 cm, with most patients (94%) having a fascial above 15 cm (W3 according to the European Hernia Society classification). The mean fascial distance was reduced from 16.1 ± 0.8 to 5.8 ± 0.7 cm (stretch gain 10.2 ± 0.7 cm, p < 0.0001, Wilcoxon matched-pairs signed-ranks test). A reduction in fascial distance of at minimum 50% was achieved in three quarters of the patients, and in half of the treated patients the reduction in fascial distance amounted to even more than 70% The closure rate achieved by fascial traction after a mean surgical duration of 207.3 ± 11.0 minutes was 90% (81/90). Postoperative complications occurred in 7 patients (8%). Re-operation was required in 4 patients (4.5%). Conclusion This described intraoperative fascia traction (IFT) method is a new, promising procedure for abdominal wall closure in large ventral hernias. The presented results demonstrate a high effectiveness, a good clinical practicability and a low complication rate of the Intraoperative fascia traction (IFT) method.

P-062 SEVERE COMPLICATION AFTER EVENTROPLASTY: NECROSIS OF RECTUS ABDOMINIS MUSCLES

Abstract Aim Rectus abdominis muscles are supplied mainly by superior and inferior epigastric arteries, forming an arcade between them. The ligation of one of them during a surgical intervention usually has no clinical repercussions. However, when both arteries flow are interrupted, there is another clinical scenario. Material and Methods We describe the case of a 74 years-old woman who was admitted for an elective surgery of fourth recurrence of a midline eventration (M2-5W3 European Hernia Society Classification). We treated using preoperative botulinum toxin and Rives-Stoppa surgical technique. On the second postoperative day, the patient suffered a cardiorespiratory arrest due to a pulmonary embolism, therefore anticoagulation was necessary. After anticoagulation the patient showed severe anemia (Hemoglobin 5 g/dL) and tomography computed scan images revealed a big hematoma of the abdominal wall with active bleeding. Results Embolization of both epigastric, right mammary and left pectoral arteries was performed by interventional radiologists. After 12 days, the patient showed cutaneous surgical wound dehiscence and serohematic foul-smelling fluid. We detected necrosis of the rectus muscles when we debrided the wound. It was treated with daily cures and vacuum therapy without mesh removal, achieving a progressive closure. After six months of follow-up, there are no signs of recurrence. Conclusions Ischemia of the rectus muscles is a severe complication after eventroplasty that can be treated with debridament of necrotic muscle and vacuum therapy, without removal of mesh if it is sufficiently extended along the healthy abdominal wall and cover the necrotic defect.

V-026 LAPAROSCOPIC TAPP REPAIR: IS IT REALLY FEASIBLE IN A RE-RECURRENT HERNIA?

Abstract Aim Describe a step by step laparoscopic transabdominal preperitoneal (TAPP) repair of a re-recurrent incisional lumbar hernia. Material & Methods This is the case of a 72-year-old man who had a previous traumatic right lumbar hernia initially approached by laparoscopic intra-peritoneal onlay mesh repair (IPOM) and its recurrence approached by open onlay mesh repair. CT-scan revealed a lumbar hernia on the right with a neck size of 40 mm. The hernia sac measured 65 mm and contained part of the right colon inside, without signs of incarceration nor dilated intestinal loops. According to the European Hernia Society classification for incisional abdominal wall hernias, the patient had a lateral hernia (L4 W2). Results Lateral incisional hernias are limited by the inguinal region inferiorly, the costal margin superiorly, the lateral margin of the rectal sheath medially and the lumbar region laterally. Due to their low incidence and the resulting lack of expertise in the treatment of this abdominal wall defect, surgical treatment poses a challenge- Conclusion The repair of a recurrent hernia is a daunting task, even more so of a re-recurrent one. By choosing to perform a TAPP repair, we were able to prove a laparoscopic re-do repair is feasible even faced with weakened tissues and distorted anatomy.

OC-011 SARCOPENIA IN COMPLEX ABDOMINAL WALL SURGERY: IMPACT ON THE POSTOPERATIVE COMPLICATIONS

Abstract Aim Sarcopenia is defined as the skeletal muscle mass loss and is considered as a prognostic factor in oncological surgical patients, liver transplant and trauma surgery. It can be reversed with exercise and diet. Nonetheless there is a lack of evidence of its impact on complex abdominal wall surgery. The aim is to evaluate the impact of sarcopenia in postoperative complications after complex incisional hernia repair. Material and Methods Retrospective study of patients undergoing surgery for complex incisional hernias >10cm (W3 of European Hernia Society classification) between 2014–2021. Sarcopenia was stablished as the skeletal muscle index (SMI), measured at L3 transversal section of a preoperative CT-scan. Previously defined literature-based SMI cutoff values were used: men <52,4cm2/m2, women <38,5cm2/m2. Results We included 105 patients, of which 29 (27,6%) were sarcopenic. The mean follow-up was 24,11 (19,28) months. The mean age and body mass index was 65,34 (10,98) and 31,85 (5,55), respectively. Sarcopenia was significantly associated with a higher risk of death [OR 11,21 (IC95% 2,76–45,52); p=0,001]. We observed a difference in need of intensive care unit (ICU) stay [OR 2,24 (IC95% 0,88–5,69); p=0,089] and cardiac complications [OR 2,96 (IC95% 0,79–11,11); p=0,108], not reaching statistical significance. Differences in surgical site occurrence or infection were not observed. After analysing by possible cofounding factors (age, comorbidities, ICU stay), sarcopenia remains associated with a higher risk of death [OR 9,08 (IC95% 2,08–39,59); p=0,003]. Conclusions Given the results of our study sarcopenia might increase the risk of death, independent of age, comorbidities and ICU stay.

Significance of routine preoperative prone computed tomography for predicting intractable cases of inguinal hernias treated by transabdominal preperitoneal repair

Physical examination is the standard diagnostic approach for adult inguinal hernias. We aimed to evaluate the clinical utility of routine preoperative computed tomography scans in the prone position for predicting intractable cases of inguinal hernias before performing transabdominal preperitoneal repairs. We retrospectively analyzed 56 lesions in 48 patients with inguinal hernias who underwent prone computed tomography scans prior to transabdominal preperitoneal repairs. To assess the ability of prone computed tomography to enable the accurate preoperative diagnosis of inguinal hernias, we compared preoperative hernia types as classified through hernia computed tomography and intraoperative diagnosis. We also analyzed the relationship between operation time and hernia type in unilateral cases (n = 40). The overall hernia computed tomography detection and classification accuracy rates were 81.0% and 83.9%, respectively, using the Japan Hernia Society classification system (2009 version) and 84.3% and 91.2%, respectively, using the European Hernia Society classification system. There were no differences in the hernia type frequencies between the shorter (n = 20) and longer (n = 20) operation time groups. Two patients had sliding inguinal hernias with prolapsing bladders, both of which were detectable using preoperative prone computed tomography. Although transabdominal preperitoneal repairs were completed in both cases, the operation times were exceptionally long (185 and 291 minute). Preoperative prone computed tomography is useful for predicting intractable cases of inguinal hernias. Prone computed tomography can play a significant role in not only typing and differentiating hernias from other diseases, but also in helping surgeons appropriately treat unexpected intractable cases with laparoscopic surgery.

Robotic vs Open Lateral Hernia Repair: A Multicenter Propensity Score–Matched Analysis of 30-day Outcomes

INTRODUCTION: Lateral ventral hernia repair (LVHR) is a challenging surgical dilemma due to location, different anatomical considerations, and low volume of cases. Our study aims to compare and assess early 30-day outcomes between open LVHR (oLVHR) and robotic-assisted LVHR (rLVHR) approach. METHODS: A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who underwent elective LVHR based on European Hernia Society classification. A 1:1 propensity score match (PSM) analysis was conducted for balanced groups. Univariate analysis was performed to compare the 2 groups (oLVHR and rLVHR) across preoperative, intraoperative, and postoperative timeframes. RESULTS: ACHQC database identified 2,569 LVHR patients. A PSM analysis stratified 665 patients to each oLVHR and rLVHR group. Median length of stay is higher in the oLVHR 3 days (interquartile range [IQR] 1 to 5) vs rLVHR 1 day (IQR 0 to 2; p < 0.001). The surgical site infection rate was higher in the oLVHR 3% vs 1% (p = 0.006). Surgical site occurrence (SSO) such as wound cellulitis was also found at a higher rate in the oLVHR 21% vs the rLVHR 0% (p < 0.001). Seroma rate was higher in the rLVHR (6.5% vs 5.6%, p < 0.001). oLVHR had 18% postoperative complication compared with rLVHR 12% (p < 0.001). There was no difference in quality-of-life measures (HerQLes and PROMIS pain 3a surveys) between groups at 30 days and 1 year. CONCLUSION: Robotic-assisted LVHR is safe with decreased length of stay and SSO compared with the conventional open approach. However, it does carry a higher seroma rate with no clinical significance.

P-086 MINIMALLY INVASIVE TREATMENT OF PARASTOMAL HERNIA: FROM THE LAPAROSCOPIC SANDWICH TECHNIQUE TO THE ROBOTIC RETROMUSCULAR TECHNIQUE

Abstract Aim Parastomal hernias are frequent and highly recurrent. The sandwich technique (ST) (Berger et al. [2007]) uses a double intraperitoneal mesh, whereas the retromuscular technique (RMT) (Pauli et al. [2016]) dissects the retromuscular space, releases the transversus muscle, and lateralizes the stoma to place a retromuscular mesh. The aim was to evaluate the results of these interventions. Matherial &amp; Methods Observational retrospective study of patients with parastomal hernia intervened by our Abdominal Wall Unit in a tertiary referral centre. The intervention performed was the ST from February 2016 to September 2020, and the RMT from September 2020 to March 2022. Results A total of 12 patients were intervened with the ST, eight laparoscopically and four robotically, and 7 patients were intervened with the RMT, all robotically. There were no statistically significant differences in basal characteristics between groups. According to the European Hernia Society classification, the parastomal hernias intervened in the ST were 16.7% type I, 33.3% type II, 16.7% type III, 33.3% type IV, while in the RMT most were type II (85.7%). The surgical time was more prolonged in the RMT. There were no statistically significant differences in early complications. Long term follow-up was longer in the ST (median: 24 months vs. 1.6 months), and the recurrences observed were 25% (3/12) for ST and 14.3% (1/7) for RMT (p:1.000). Conclusions RMT is a challenging procedure with similar rate of early complications and promising relapse results despite a shorter follow-up. It is currently our procedure of choice for parastomal hernia.

Zig Maneuver in Total Extraperitoneal Inguinal Hernia Repair.

The difficulties in the hernia sac dissection in repairing large inguinal hernias with the endoscopic total extraperitoneal (TEP) technique prolong the operation and increase the risk of injury. This study investigates the effectiveness of the Zig maneuver (ligation of the hernia sac at the deep inguinal ring) in TEP in male patients with L3 inguinal hernia by European Hernia Society classification. A total of 224 male patients with L3 inguinal hernia who underwent laparoscopic TEP surgery in 2018 and 2019 were retrospectively screened and included in the study. The patients were divided into 2 groups as Zig group (n=99) and the non-Zig group (n=125), depending on whether the Zig maneuver was performed during TEP application. The mean patient age was 45.49 for the non-Zig group and 47.12 for the Zig group. The median operative time was 50 minutes in the non-Zig group and 43 minutes in the Zig group (P<0.005). The median value of the postoperative first 24 hours pain score was 3 in the non-Zig group and 2 in the Zig group (P=0.033). Scrotal edema was 7.2% in the non-Zig group and 1% in the Zig group (P=0.023). According to logistic regression analysis, the Zig maneuver reduced the probability of scrotal edema by 87% in almost the entire population (odds ratio=0.130, 95% confidence interval: 0.016-1.047). There was no statistically significant difference between the groups in terms of early and late recurrence. Zig maneuver shortened the operative time and significantly reduced the feeling of pain in the first 24 hours postoperatively in male patients with indirect L3 hernia who underwent endoscopic TEP. It also significantly reduced the likelihood of scrotal edema in almost the entire population. As a result, the Zig maneuver is an effective method that could be applied during endoscopic TEP.

Internal Ring Defect Closure Technique in Laparoscopic Mesh Hernioplasty for Indirect Inguinal Hernia.

PurposeThe best way to reduce seroma formation after laparoscopic indirect hernia repair is debated. We noticed that internal ring defect closure in laparoscopic mesh hernioplasty could provide promising outcomes with an effect on diminishing seroma formation. We introduce our closure technique and report our experience.MethodsThis prospective study was conducted from May 2019 to May 2021. Patients with European Hernia Society classification L3 indirect or scrotal hernia were recruited and underwent laparoscopic transabdominal patch plasty (TAPP). Hernia defect closure was performed before mesh deployment. The primary outcomes were seroma formation, postoperative pain, and hernia recurrence. Perioperative data and postoperative complications were also recorded.ResultsConsecutive 77 patients with 89 indirect hernias (including 51 scrotal hernias) were recruited in two regional tertiary hospitals. All operations were successful without open conversion. The mean size of the hernia defect was 3.7 ± 0.5 cm (range, 2.5–5.0 cm). The mean operative time for each hernia repair (peritoneum to peritoneum) was 48.3 ± 10.8 min (range, 33–72 min), and the mean time required for internal ring closure was 6.7 ± 2.2 min (range, 4–10 min). Intraoperative bleeding was minimal. The mean visual analog scale pain score at rest on the first postoperative day was 2.2 (range, 1–4). The average postoperative length of hospital stay was 18 h (range, 14–46 h). During a mean follow-up period of 9.4 months (range, 3–23 months), no hernia recurrence or chronic pain were noted. Seroma formation was detected on six sides of unilateral hernias (6.7%) on postoperative day 7, with a mean volume of 45.8 ml (range, 24–80 ml). All seromas were mild and resolved spontaneously within 3 months, with no need for evacuation or other treatment and without major impact on the final outcome.ConclusionsDefect closure in laparoscopic mesh hernioplasty for large indirect hernias is safe and feasible and can significantly reduce postoperative seroma formation and relative complications. This approach is recommended in large indirect or scrotal hernia repair.

Totally extraperitoneal inguinal hernia repair versus Lichtenstein repair: a one-year follow-up study

The inguinal hernia has an incidence of 27 — 43 % in males. Surgical repair is the most accepted treatment to prevent the development of complications. Laparoscopic inguinal hernia repair has become popular worldwide and includes the use of a laparoscopic technique for mesh placement behind the defect. Objective — to assess whether totally extraperitoneal (TEP) inguinal hernia repair shows benefits over Lichtenstein repair in intraoperative and one‑year follow‑up postoperative outcomes for male patients with primary unilateral inguinal hernia. Materials and methods. 53 males were randomly allocated to two groups. Group 1 included 27 patients who underwent totally extraperitoneal hernia repair using self‑gripping lightweight mesh, and group 2 included 26 patients who were treated surgically with Lichtenstein repair using lightweight mesh. Results. Both groups were comparable in mean age, type of hernia, body mass index and patient’s distribution according to the European hernia society classification. TEP repair takes on average a little less time as compared to Lichtenstein repair, and this difference is not statistically significant. The mean of visual analogue scale for pain scoring in the first 24 hours after surgery as well as in the next 24 hours is statistically significantly smaller in group 1 compared to group 2. The mean time taken to return to work was 2.15 times longer in group 2 than in group 1, and the difference was statistically significant. Conclusions. Totally extraperitoneal hernia repair shows potential benefits over Lichtenstein repair for primary unilateral inguinal hernias as it causes less pain in the postoperative period and ensures early return to work.

Extended View Totally Extraperitoneal Technique and Its Advantages in Laparoscopic Inguinal Hernia Repair.

Objective: Endoscopic total extraperitoneal (TEP) is used increasingly in inguinal hernias. Perhaps the most fundamental difficulty of the classical TEP method is that the dissection plan it offers is overly limited, which is among the reasons why techniques other than TEP are preferred in large scrotal hernias. This study discusses our experience with the extended view totally extraperitoneal (e-TEP) method, which significantly expands the dissection plan compared to the classical method. Methods: Patients who had inguinal hernia surgery in 2018 and 2019 were retrospectively analyzed, and 21 male patients with L3 inguinal hernia by European Hernia Society classification, who underwent laparoscopic e-TEP surgery, were included in the study. Patient data were obtained from the hospital's electronic database and patient files. One year after the surgery, the patients were invited to the hospital by telephone and re-examined. Results: The median patient age was 47 years. The mean duration of surgery was 43.6 minutes, and the median postoperatively pain score in the first 24 hours was 1.975. Zig maneuver was performed in 85.7%, and drains were placed in 33.4% of patients. In 28.6% of patients, the peritoneal violation occurred. However, there was no conversion to another surgical technique. The mean length of stay was 1.33 days. Two patients had seroma, one had scrotal edema, and one had urinary retention. No recurrence was observed in any patient during the 1-year follow-up. Conclusions: According to our experience, the e-TEP technique can be safely performed in scrotal hernias as it offers a larger dissection plane. It also allows patients with large scrotal hernias to benefit from all the advantages of the TEP technique.

Management of lateral abdominal wall hernias

Lateral abdominal wall hernias are rare and inconsistently defined, which is why the use of the European Hernia Society classification makes sense, not least for the purpose of comparing the quality of surgical results. Adistinction must be made between true fascial defects and denervation atrophy. Based on the available literature, there is generally alow level of evidence with no consensus on the best operative strategy. The proximity to bony structures and the complex anatomy of the three-layer abdominal wall make the technical treatment of lateral hernias difficult. The surgical variations include laparoendoscopic, robotic, minimally invasive, open or hybrid approaches with different mesh positions in relation to the layers of the abdominal wall. The extensive preperitoneal mesh reinforcement open, transabdominal peritoneal (TAPP) laparoscopic repair or total extraperitoneal (TEP) endoscopic repair has met with the greatest approval. The extent of the required medial mesh overlap is determined by the distance between the medial defect boundary and the lateral edge of the straight rectus abdominus muscles. The medially directed preperitoneal and retroperitoneal dissection can be extended into the homolateral retrorectus compartment by laterally incising the posterior rectus sheath or by crossing the midline behind the intact linea alba into the contralateral retrorectus compartment. The intraperitoneal onlay mesh (IPOM) technique is asuitable procedure only for smaller defects with possible defect closure but it is also important as an exit strategy in the case of adefective peritoneum. Individualized prehabilitative and preconditioning measures are just as important as the assessment of preoperative anamnestic and clinical findings and risks with radiographic cross-sectional imaging diagnostics.

Trentino Hernia Team Technique Plus Endoscopic Transversus Abdominis Release for Large Ventral Incisional Hernias: Description of the First Case

Trentino Hernia Team Technique Plus Endoscopic Transversus Abdominis Release for Large Ventral Incisional Hernias: Description of the First Case

The role of radiological classification of parastomal hernia as a predictor of the need for surgical hernia repair: a retrospective cohort study

Parastomal hernia (PSH) is a frequent complication of stoma creation during colorectal surgery. Radiological classification systems have been proposed for PSH but are primarily used for research. Our objective was to determine if PSH radiological classification at diagnosis could predict the need for surgical repair during follow-up. In this retrospective cohort study, we reviewed 705 postoperative CT scans from 154 patients with permanent stoma creation from 2015 to 2018. Patients were included for analysis if a primary PSH was diagnosed on any exam. PSH were classified according to the European Hernia Society (EHS) and Moreno-Matias (MM) classification systems. The incidence of radiological PSH was 41% (63/154) after a median radiological follow-up of 19.2 months (interquartile range, 10.9-32.9). Surgical repair was required in 17 of 62 patients with a primary PSH. There was no significant correlation between PSH classification and surgical hernia repair for either the EHS (p = 0.56) or MM classification systems (p = 0.35) in a univariate analysis. However, in a multivariate analysis, the type of PSH according to the EHS classification was significantly correlated with PSH repair during follow-up (p = 0.02). Type III PSH were associated with a lower incidence of surgical hernia repair as compared with type I, with a hazard ratio (HR) of 0.01 (95% CI, <0.00-0.20). A similar correlation was not seen using the MM classification (p = 0.10). EHS classification of PSH was significant correlated with the need for surgical repair during short-term follow-up. Prospective studies are required to establish a potential role in patient care.

Simultaneous Complex Incisional Hernia Repair and Bariatric Surgery for Obese Patients: a Case Series of a Single-Center Early Experience.

Obesity is associated with recurrence of complex incisional hernia repair (CIHR). Bariatric procedure during CIHR can improve recurrence rates without increasing morbidity. This study aimed to describe our results after CIHR in patients with obesity, in which a simultaneous bariatric procedure was performed. We performed a retrospective observational study including patients who underwent surgery between January 2014 and December 2018, with a complex incisional hernia (CIH) according to the Slater classification and body mass index (BMI) ≥35. CIHR was the main indication for surgery. We collected demographic data, comorbidities, CIH classification according to the European Hernia Society, type of bariatric procedure, postoperative morbidity using the Dindo-Clavien classification, and short-term results. Computed tomography (CT) is performed preoperatively. Ten patients were included in the study (7 women). The mean BMI was 43.63±4.91 kg/m2. The size of the abdominal wall defect on CT was 8.86±3.93 cm. According to the European Hernia Society classification, all CIHs were W2 or higher. Prosthetic repair of the CIH was selected. Onlay, sublay, preperitoneal, and inlay mesh placement were performed twice each, as well as one modified component separation technique and one transversus abdominis release. Gastric leak after sleeve gastrectomy was the only major complication. Short-term outcomes included one recurrence, and % total weight loss was 24.04±8.03 after 1-year follow-up. The association of bariatric procedures during CIHR seems to be feasible, safe, and could be an option for surgical treatment in selected patients.

Prophylactic Single-use Negative Pressure Dressing in Closed Surgical Wounds After Incisional Hernia Repair: A Randomized, Controlled Trial.

A randomized controlled trial (RCT) was undertaken to evaluate whether the prophylactic application of a specific single-use negative pressure (sNPWT) dressing on closed surgical incisions after incisional hernia (IH) repair decreases the risk of surgical site occurrences (SSOs) and the length of stay. The sNPWT dressings have been associated to several advantages like cost savings and prevention of SSOs like seroma, hematoma, dehiscence, or wound infection (SSI) in closed surgical incisions. But this beneficious effect has not been previously studied in cases of close wounds after abdominal wall hernia repairs. An RCT was undertaken between May 2017 and January 2020 (ClinicalTrials.gov registration number NCT03576222). Participating patients, with IH type W2 or W3 according to European Hernia Society classification, were randomly assigned to receive intraoperatively either the sNPWT (PICO)(72 patients) or a conventional dressing at the end of the hernia repair (74 patients). The primary endpoint was the development of SSOs during the first 30 days after hernia repair. The secondary endpoint included length of hospital stay. Statistical analysis was performed using IBM SPSS Statistics Version 23.0. At 30 days postoperatively, there was significatively higher incidence of SSOs in the control group compared to the treatment group (29.8% vs 16.6%, P < 0.042). There was no SSI in the treatment group and 6 cases in the control group (0% vs 8%, P < 0.002). No significant differences regarding seroma, hematoma, wound dehiscence, and length of stay were observed between the groups. The use of prophylactic sNPWT PICO dressing for closed surgical incisions following IH repair reduces significatively the overall incidence of SSOs and the SSI at 30 days postoperatively.