Recurrent Incisional Hernia Research Articles

BHSeP46 Growing from strength to strength—results from a tertiary abdominal wall reconstruction centre

Abstract Introduction Abdominal wall reconstruction (AWR) is now well-established as a sub-speciality in general and plastic surgery. We present the results of our well-established high-volume multi-disciplinary team (MDT) from a tertiary referral centre. Methods Retrospective review of cases from weekly abdominal wall reconstruction MDT from 01 June 2016—31 May 2024 was done. Key stakeholders included 3 Consultants in General surgery and 3 in Plastic surgery, 2 Consultant Anaesthetists and dedicated AWR MDT co-ordinator. Results are presented as Average (range). Results During the study period, 3078 patients have been discussed. This includes referrals from other hospitals. We have performed 123 (109–145) AWR operations per year. Mean BMI 30.5 (16.9–55.4). More than 95% of the patients received pre-operative Botox injections which were done by a Single Consultant Anaesthetist as a day case procedure. 78% underwent Rives-Stoppa procedure and 22% underwent posterior component separation with <4% patients who underwent bridging. 96% patients underwent concomitant abdominoplasty/panniculectomy (vertical, transverse, fleur-de-lis) with radical skin and sub-cutaneous fat excision weighing average of 1611 (150–18 000) grams. Bio-synthetic absorbable mesh was used in >80% of the patients. Return to theatre was 1.5% with 30-day mortality <0.5%. Incisional hernia recurrence rate was <3% (excluding the patients who underwent bridged repair). 150 patients remain on our waiting list to be operated. Conclusion We have demonstrated, again, that working in an MDT for such highly complex group of patients works very well, giving excellent outcomes. Team working with general and plastic surgeons has offered our patients a true multi-disciplinary knowledge and skills.

Enhanced view totally extraperitoneal approach: The best available option for recurrent incisional hernias following previous laparoscopic intraperitoneal onlay mesh plus repairs.

The available options for recurrent incisional hernias (RIH) following previous laparoscopic intraperitoneal onlay mesh (IPOM) plus were open onlay repair, open Rives-Stoppa (RS), laparoscopic enhanced view totally extraperitoneal-RS (ETEP-RS) and laparoscopic subcutaneous onlay mesh repair. Majority of these RIH were managed by open onlay mesh repairs or laparoscopic Redo IPOM plus. There are not much data available in the literature on the ETEP approach for RIH following previous IPOM plus with the placement of mesh in the retrorectus space. In this article, I would like to share technical aspects, challenges faced and tips to overcome these challenges of performing ETEP for RIH following previous IPOM plus repairs.

Quality of life and abdominal wall functionality after abdominal wall reconstruction: A prospective single center follow-up study

BackgroundFascial breakdown with the occurrence of an incisional hernia (IH) is an important and challenging complication of any laparotomy. For a long time, the success of the abdominal wall reconstruction (AWR) was measured only from the surgeon’s perspective by defining outcome measures such as wound morbidity and recurrence. The understanding that complete recovery is difficult to assess without considering patients has shifted the paradigm of optimal outcomes to Patient Reported Outcome Measures (PROMS) and Quality of Life (QoL), which are pivotal to evaluate the success and efficacy of AWR.MethodsWe conducted a prospective follow-up study of 91 patients undergoing mesh-augmented abdominal wall reconstruction for primary or recurrent incisional hernia between January 2021 and December 2023. Demographic data, comorbidities, and hernia characteristics were recorded. All patients were evaluated preoperatively by a native abdomino-pelvic CT scan to assess the characteristics of hernia (length, width, surface, and volume of the incisional hernia sac and of peritoneal cavity), the presence of mesh (if previously inserted), and abdominal wall muscles status. All intervention were performed by the same surgical team according to the techniques described by Rives – Stoppa (RS), Ramirez (ACS), and Novitsky (PCS). Abdominal wall function was assessed using trunk raising (TR) and double leg lowering (DLL) measurements performed preoperatively, 1 month, 6 months, and 1 year postoperatively. At the same time, pre- and post-operative quality of life was analysed using the EQ-5D score.ResultsMean age of 59.42 ± 12.28 years and a male/female ratio of 35/56 were recorded, most of them being obese. There were 36 (42%) patients with defects larger than 10 cm. The distribution of the type of surgical intervention was: RS 35 patients, ACS 13 patients, and PCS 43 patients. The mean value of combined score for the preoperative abdominal wall functionality was 4.41 ± 1.67 (2–8) while the mean value of preoperative EQ-5D index was 0.652 ± 0.026 (-0.32–1.00). QoL was poor and very poor for 48% (44) of the patients who recorded index values less than 0.56 (50% percentile). Preoperative EQ-5D index was highly correlated with Combined AWF score (r = 0.620; p < 0.0001) and the correlation was specific (AUC = 0.799; p < 0.0001; asymptotic 95%CI = 0.711–0.923). At 12 months, the AWF score increased to 8.13 ± 2.58 (1–10) and the QoL total score to 0.979 ± 0.007 (0.71–1). Good and very good total scores for QoL were recorded for 47 patients (84%) compared to 33 (36%) in the preoperative evaluation (χ2 with Yates continuity correction for two degrees of liberty = 46.04; p < 0.00001).ConclusionOur results suggest that patients can expect to see a significant overall improvement in all five components of QoL measured with the help of Eq. 5D questionnaire. This improvement is dependent by hernia size, and some individual patient’s factors (diabetes, cardiovascular diseases, and age over 60 years).

SURGICAL TREATMENT FOR ADVANCED COLORECTAL CANCER WITH ABDOMINAL WALL INVASION AND IMPLANTATION

Abstract Aim The prognosis of abdominal wall invasion and implantation from colorectal cancer (CRC) is not good. With radical resection and abdominal wall reconstruction (AWR) technique, locally advanced CRC patients with resectable abdominal wall invasion and implantation may achieve longer tumor-free survival time and an improved quality of life. Methods 15 patients were retrospectively analyzed. All patients underwent preoperative three-dimensional visualization reconstruction of the abdominal wall and evaluation with a multidisciplinary team (MDT). Patient information, including tumor size, defect size, operation time, intraoperative bleeding, length of hospital stays, and other factors, was collected. Results All 15 locally advanced CRC patients with abdominal wall invasion and implantation underwent radical abdominal wall tumor resection followed by AWR. The average tumor dimension and abdominal wall defects after resection were 98.13 ± 71.70 and 270.07 ± 101.95 cm2 respectively; and accurate abdominal wall classification and zoning were obtained for all patients. The average operation time was 431.7 ± 189.2 min, and the average blood loss was 513.3 ± 244.6 ml. The incidence of incisional hernia and CRC recurrence were 6.0% and 13.3%, respectively. Conclusions With comprehensive preoperative evaluation, results of radical resection of abdominal wall invasion and implantation in locally advanced CRC patients is satisfactory and safe.

Risk factors of recurrence after incisional hernia preperitoneal repair: a long-term retrospective single-center cohort study.

To explore the risk factors for incisional hernia (IH) recurrence following open prepertioneal repair. Patients diagnosed with primary IH who underwent open preperitoneal repair at our hospital were enrolled. Patients were assessed, and perioperative factors were collected. Recurrence surveys were performed at regular intervals throughout the long-term postoperative follow-up. The risk factors for IH recurrence were identified using univariate and multivariate analyses. This study included 145 patients. Significant differences were found between recurrence and non-recurrence patients regarding pulmonary ventilation function (PVT), age, body mass index (BMI), mesh materials, type of surgery (clean, clean-contaminated, or contaminated), surgical site infections (SSIs), maximum width of the hernia defect (MWHD), and site of incisional hernia (P < 0.01). The univariate survival analysis revealed that PVT abnormalities, age > 70 years, BMI > 27kg/m2, porcine small intestine submucosal (PSIS) mesh, non-clean surgery, SSIs, MWHD > 10cm, and location in the lateral zones were significant factors for IH recurrence after open preperitoneal repair. The multivariate survival analysis showed that PVT abnormalities, age > 70 years, BMI > 27kg/m2, and PSIS mesh were independent risk factors for IH recurrence after open preperitoneal repair. We identified PVT abnormalities, age > 70 years, BMI > 27kg/m2, and PSIS mesh as novel risk factors for IH recurrence after open preperitoneal repair.

A Comparative Study of Elective Sublay Versus Onlay Repair for Non-complex, Small, and Medium-Size Incisional Hernia: Post-operative Complications in a Tertiary Hospital in Ranchi, India.

The most difficult hernia surgery is the repair of the ventral hernia, which is caused by aberrant organ or tissue protrusions through the abdominal wall. Factors like obesity, smoking, and chronic medical conditions contribute to their formation. Surgical strategies have evolved from anatomical repair to mesh hernioplasty, with mesh placement playing a significant role in outcomes. The ideal anatomical location for mesh placement remains debated due to varying results. So, the objective of the study is to compare early postoperative complications, surgical site infection, and incidence of recurrence between sublay and onlay mesh placement repair of incisional hernias of <10 cm in diameter, at a tertiary hospital in Ranchi. This retrospective comparative study was conducted over a period of January 2022 to January 2024 at the Rajendra Institute of Medical Science, Ranchi, India. During the study period, 96 patients were operated on, and their demographic details, along with their position of mesh placement and postoperative complications (seroma formation, wound infection, postoperative hospital stays, and recurrence), were retrieved from the hospital data. Comparisons between onlay and sublay groups in terms of post-operative complications were made. Within the study period, a total of 96 patients were operated on for incisional hernia. In this study, 36 (37.5%) were male and 60 (62.5%) were female, with a male-to-female ratio of 0.6:1. Out of the total number of patients, 56 (58.4%) had a past history of emergency surgery. It was observed that there was a higher incidence of seroma formation in the onlay group compared to the sublay with a statistical significance p-value of 0.027. The incidence of wound infection was found to be statistically significant (p-value = 0.035) between the onlay and sublay groups. In a period of six-month follow-up, three patients of the total study population had an incidence of recurrent incisional hernia, of which two from the onlay group and one from the sublay group were present, and there was no statistical significance (p-value > 0.5). Based on our retrospective analysis, we can say that there is a lower incidence of postoperative complications and recurrence in sublay repair, along with a shorter postoperative hospital stay, making it a preferred method of repair over onlay.

The Benefit of Open Rives-Stoppa Procedure in Complex Incisional Hernia.

Introduction: Ventral hernia is one of the most common general surgical pathologies. An incisional hernia will develop in 10–15% of patients with an abdominal incision, and the risk increases to up to 23% in those who develop surgical site infections.&#x0D; Ventral hernia repairs are mostly elective (90%) procedures, but the repair methods are highly variable.&#x0D; Popularized in Europe by Rives and Stoppa, the retromuscular technique has proven to be very effective, with a 94.2% probability of having the lowest odds for recurrence and a 77.3% probability of having the lowest odds for SSI.&#x0D; The study aimed to evaluate our experience at a secondary care center performing Rives-Stoppa repair for abdominal ventral and incisional hernias.&#x0D; Materials and Methods: Between April 2019 and August 2021, 46 patients in the practice at a secondary regional hospital, Teni Konomi, Korce, Albania, underwent a Rives-Stoppa incisional hernia repair.&#x0D; Results: There were 14 (31%) males and 32(69%) females (age range 31-75).&#x0D; Most incisional hernias were midline xiphoid-pubic incision and supraumbilical, with several subcostals (2 right and 1 left) hernias.At the time of repair, most incisional hernias were symptomatic and evident on physical exam. In four cases, the hernia sac was incarcerated at the presentation time.&#x0D; Conclusion: The Rives-Stoppa technique has excellent long-term results and low morbidity in patients with large primary or recurrent incisional hernias. It is the gold standard for most surgeons.&#x0D; Keywords: Incisional Hernia, mesh, polypropylene, abdominal wall surgery, rectus muscle

The INCH-trial: a multicenter randomized controlled trial comparing short- and long-term outcomes of open and laparoscopic surgery for incisional hernia repair

BackgroundLaparoscopic incisional hernia repair is increasingly performed worldwide and expected to be superior to conventional open repair regarding hospital stay and quality of life (QoL). The INCisional Hernia-Trial was designed to test this hypothesis.MethodsA multicenter parallel randomized controlled open-label trial with a superiority design was conducted in six hospitals in the Netherlands. Patients with primary or recurrent incisional hernias were randomized by computer-guided block-randomization to undergo either conventional open or laparoscopic repair. Primary endpoint was postoperative length of hospital stay in days. Secondary endpoints included QoL, complications, and recurrences. Patients were followed up for at least 5 years.ResultsHundred-and-two patients were recruited and randomized. In total, 88 patients underwent surgery and were included in the intention-to-treat analysis (44 in the open group, 44 in the laparoscopic group). Mean age was 59.5 years, gender division was equal, and BMI was 28.8 kg/m. The trial was concluded early for futility after an unplanned interim analysis, which showed that the hypothesis needed to be rejected. There was no difference in primary outcome: length of hospital stay was 3 (range 1–36) days in the open group and 3 (range 1–12) days in the laparoscopic group (p = 0.481). There were no significant between-group differences in QoL questionnaires on the short and long term. Satisfaction was impaired in the open group. Overall recurrence rate was 19%, of which 16% in the open and 23% in the laparoscopic group (p = 0.25) at a mean follow-up of 6.6 years.ConclusionsIn a randomized controlled trial, short- and long-term outcomes after laparoscopic incisional hernia repair were not superior to open surgery. The persisting high recurrence rates, reduced QoL, and suboptimal satisfaction warrant the need for patient’s expectation management in the preoperative process and individualized surgical management.Trial registrationNetherlands Trial Register NTR2808.

Incisional hernias post renal transplant: a systematic review and meta-analysis.

Incisional hernia (IH) post renal transplant (RT) is relatively uncommon and can be challenging to manage clinically due to the presence of the kidney graft and patient immunosuppression. This systematic review and meta-analysis synthesises the current literature in relation to IH rates, risk factors and outcomes post RT. PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials (CENTRAL) were searched up to July 2023. The most up to date Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines were followed. Pertinent clinical information was synthesised. A meta-analysis of the pooled proportions of IH rates, the rates of patients requiring surgical repair and the rates of recurrence post RT are reported. Twenty studies comprising 16,018 patients were included in this analysis. The pooled rate of IH occurrence post RT was 4% (CI 3-5%). The pooled rate of IH repair post RT was 61% (CI 14-100%). The pooled rate of IH recurrence after repair was 16% (CI 9-23%). Risk factors identified for IH development post RT are BMI, immunosuppression, age, smoking, incision type, reoperation, concurrent abdominal wall hernia, lymphocele formation and pulmonary disease. IH post RT is uncommon and the majority of IH post RT are repaired surgically on an elective basis.

313 Preoperative CT Imaging: A Tool to Predict Incisional Hernia Outcomes Following Abdominal Wall Reconstruction

Abstract Aim Abdominal wall reconstruction (AWR) is a surgical technique used to manage recurrent incisional hernias, which cause significant morbidity and are difficult to treat. In this study, we sought to determine whether subcutaneous abdominal fat thickness (AFT) measured at the xiphoid process, umbilicus, and pubic tubercle using preoperative CT scans could predict postoperative outcomes in patients undergoing AWR. Method 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 analysed using statistical tests. Results The results showed that 9 out of 101 patients (8.9%) experienced hernia recurrence. Smoking was significantly associated with an increased risk of hernia recurrence (p&amp;lt;0.001) and had a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus (p&amp;lt;0.001), and pubic tubercle (p&amp;lt;0.001) were also associated with hernia recurrence and additionally with risk of infection. However, only AFT at the pubic tubercle reached significance in the multivariate logistic regression model predicting recurrence (OR = 1.10; p = 0.030) and infection (OR = 1.04; p = 0.021). Conclusions In conclusion, smoking and increased subcutaneous abdominal fat thickness at the pubic tubercle are significant risk factors for recurrence and infection in patients undergoing abdominal wall reconstruction, and preoperative optimisation should focus on reducing these factors.

Outcomes of recurrent incisional hernia repair by open and laparoscopic approaches: a propensity score-matched comparison.

Recurrent incisional hernias are challenging, and their surgical outcomes have not been well studied. We aimed to analyze the outcomes of recurrent incisional hernia repair in a propensity score-matched cohort study on laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) versus open sublay repair. All consecutive patients who had undergone open sublay repair and lap. IPOM of recurrent incisional hernia between January 2015 and December 2021 at a tertiary hernia center was identified. One-to-one propensity score matching was used to achieve a balanced exposure groups at baseline. Of 255 patients, 85/95 with open sublay repair were matched to 85/160 with lap. IPOM. Before matching, the open sublay group had significantly larger hernia defects (6.3cm vs. 5.0cm) than the lap. IPOM group. Other major baseline imbalances were also found in body mass index (BMI), obesity and European Hernia Society (EHS) width classification. The pre-match results showed that the lap. IPOM group had significantly shorter operative time (median 75 vs. 95min) and shorter postoperative hospital stay (median 8 vs. 11days) compared with the open sublay group. Wound infection (8.4% vs. 1.9%) and hematoma (5.3% vs. 0.6%) occurred more frequently after open sublay repair. After matching, baseline characteristics were well balanced. The recurrence rate and incidence of complications were comparable between the two groups. However, the post-match analysis still showed that lap. IPOM was associated with decreased length of postoperative stay. The outcomes of recurrent incisional hernia surgery after lap. IPOM and open sublay repair appear similar, except that the former had shorter length of postoperative stay. However, the poor outcomes were more likely associated with the unfavorable risk profiles, such as larger defect size, rather than the procedure technique itself.

Association of Nicotine Cessation Time on the Incidence of Recurrent Incisional Hernia Repair and Postoperative Surgical Site Occurrences.

Nicotine products are believed to be associated with a higher incidence of incisional hernia (IH) recurrence and postoperative complications after IH repair. A retrospective analysis of the Abdominal Core Health Quality Collaborative (ACHQC) database was performed. Outcomes included risk of IH recurrence, 30-day surgical site infection (SSI), and 30-day surgical site occurrence (SSO). We included 14,663 patients. Nicotine users who quit within 1year of surgery had a 26% higher risk of IH recurrence compared to patients who quit more than a year before surgery or never users. Patients who quit using nicotine within 1year of surgery had a 54% higher odds of SSI compared to former nicotine users who quit more than a year before surgery. Former nicotine users with less than 1year of nicotine use cessation before surgery exhibited worse outcomes than those with more than a year of cessation or no prior use.

P-033 COMPLICATIONS IN E-TEP RIVES:OUR SERIE

Abstract Aim To study complications in our e-TEP series in ventral and incisional hernias. Methods We reviewed all patients undergoing e-TEP for ventral or incisional hernias. We included 33 patients (14 M2 or M3W2 incisional hernias and 11 medium ventral hernias with rectus diastasis), in whom polypropylene mesh was used. Follow-up at least 6 months. Results We found 2 patients with interstitial hernia below the mesh, one of them in the acute postoperative period with intestinal obstruction. One patient with recurrence of incisional hernia in the subxiphoid area, one patient with asymmetry of the right hypochondrium, and one patient with a seroma requiring drainage and a hematoma in another (using drainage). Intensive postoperative pain in 6 patients with delayed discharge. Conclusion In our series, E-TEP is safe but not free of complications.We started the procedure very ambitiously with M3W2 incisional hernias, but we soon realized that this technique did not allow us to revise the cavity and perform adhesiolysis, so we changed the way we managed these patients, and became more selective, only indicating E-TEP in medium-sized primary hernias associated with rectus diastasis. We managed to improve surgical skill with the cases, reducing postoperative pain, surgical time and hospital stay.

P-078 IMPLEMENTATION OF THE HOSPITAL-AT-HOME UNIT IN THE POSTOPERATIVE COMPLEX ABDOMINAL WALL

Abstract Abreviations EHS: European Hernia Society Aim Show the results of the application of a new service in our hospital, Hospital-at-Home, in the postoperative period of incisional hernias and complex abdominal wall. Material and Methods Retrospective analysis of operated patients in our center in 30 month period (July 2020 - December 2022) with complex abdominal wall. Patients who accept home follow-up with Hospital-at-Home unit and who corresponded to the geographical area. Patients with incisional midline hernia are included: more than two locations -M- in the classification of the EHS or width greater than 4 cm (W2). Lateral incisional hernias with more than two locations -L- are also included in the EHS classification and complex parastomal hernias. Results 25 patients, 17 men and 8 women, underwent both elective and urgent incisional hernia surgery. The surgical techniques used were retromuscular mesh repair, posterior component separation and onlay technique (emergency cases). Mean hospital stay was 4.5 days. Later the patients were visited by Hospitalization at Home. There were 2 surgical wound infections treated with intravenous antibiotics and a need for reoperation (Grade II and IIIa of Clavien-Dindo classification of surgical complications. Recurrent incisional hernia was observed in 1 patient. Conclusions Benefits of Hospitalization at Home by improving the degree of patient satisfaction, reducing the hospital stay and not worsening the clinical safety of the patient with complications.

P-024 INITIAL EXPERIENCE OF EXTENDED TEP REPAIR FOR VENTRAL AND INCISIONAL HERNIAS IN OUR HOSPITAL

Abstract Aim The purpose of this study was to investigate the treatment outcomes and feasibilities of the enhanced view totally extraperitoneal (eTEP) repair for ventral and incisional hernias in our hospital. Material &amp; Methods We retrospectively reviewed the medical records of patients who underwent eTEP repair for ventral and incisional hernias in our hospital from October 2018 to April 2022. Demographic information, preoperative evaluations, intraoperative variables, postoperative outcomes were collected and analyzed. The surgical techniques were followed the article published by Daes et al in 2021. Results Thirty-two patients underwent eTEP repair during the study period. These patients had mean age of 60.8 years, mean BMI 27.1 kg/m2, and median ASA score 2. Twenty-six had incisional hernias (4 were recurrent incisional hernias) and six were primary ventral hernias. Nineteen had hernias in M3 location, mean defect width and length size were 6.00 and 7.47 cm. Sixteen had diastasis rectis and eight had incarcerations at the time of surgery. Twenty-eight underwent eTEP Rives-Stoppa (RS) repair (23 the conventional laparoscopic ports, 2 reduced ports, 1 single port, and 1 robotic). Four underwent eTEP transversus abdominis release (TAR) using the conventional laparoscopic ports. Mean operation time was 199 (±48.5) minutes and mean estimate blood loss volume was 25.8 (±27.2) ml. The common postoperative complications were seroma and voiding difficulty and mean hospital stay length was 8.25 (±4.45) days. There were two recurrences within follow-up period. Conclusion Our initial experience of eTEP repair for ventral and incisional hernias showed favorable treatment outcomes and feasibilities.

OC-089 A CHALLENGING REPAIR OF RECURRENT VENTRAL HERNIA IN A PATIENT WITH A PREVIOUS INTRAPERITONEAL MESH AND ABDOMINOPLASTY

Abstract Aim To understand the challenges faced in repair of recurrent ventral hernia in a patient with a previous intraperitoneal mesh and abdominoplasty. Introduction Ventral hernias still represent a great challenge for surgeons, especially if they are recurrent. We present a 54-year-old overweight female with complex surgical history and a recurrent incisional hernia. She had a laparoscopic cholecystectomy and port site hernia which was repaired without a mesh. She later underwent a Roux-en-Y Gastric bypass for obesity and developed another port site hernia in lower epigastrium. The incisional hernia was repaired with an intraperitoneal mesh. Finally, she had an abdominoplasty for cosmetic reasons. She presented to our surgical clinic with a clinically palpable recurrent large incisional hernia. Methods The repair was carefully planned with a CT abdomen confirming a 6 cm defect in the upper midline and a large intraperitoneal mesh with multiple metallic tacks. The surgical procedure was as follows: Midline incision and careful dissection of the sac. The intraperitoneal mesh was identified and removed carefully keeping the posterior rectus sheath and peritoneum intact. A posterior component separation technique was performed. Posterior rectus sheath was closed with interrupted absorbable sutures. A tailored polypropylene mesh was placed in retro-rectus space. The anterior rectus sheath was closed with non-absorbable interrupted sutures. Patient had an uneventful postoperative period and was discharged on the third postoperative day. Conclusion Careful patient selection, detailed preoperative planning and expertise in abdominal wall reconstruction result in a successful repair of complex ventral hernias.

P-080 THE GRIP CONCEPT CONSIDERS BIOMECHANICAL PRINCIPLES FOR A DURABLE REPAIR OF INCISIONAL HERNIA – 3 YEAR FOLLOW UP

Abstract Aim Durable hernia repair is based on specific biomechanical principles. How are the results after three years in primary and recurrent hernias? Material and methods The biomechanical principles were analyzed ex vivo with cyclic loading using a self-built bench test. The minimal requirements for a biomechanically durable repair were defined. The resulting GRIP concept was clinically applied. Results A total of 233 patients (123 males and 110 females) were treated for incisional hernia. Primary hernia was repaired in 170, recurrence in 63 patients with an average of 1.3 risk factors with most patients grouped as ASA III (n= 120). Emergency repairs were necessary in 11 patients. Hernia orifices were mostly median (N= 209) and lateral (89 patients, 59 combined). Hernia sizes were on average 9 + 6 cm wide and 13 ± 8 cm long. The mesh-defect area ratio was 7.8. Fixation was necessary (median of 60 fixation points). Recurrences required more effort for a durable repair (Primary OR duration: 165 ± 75 min; recurrence: 233 ± 89 min). A total of 138 patients were followed for three years so far. Four patients died during follow-up (Follow-up rate 100%). A second hernia in the un-repaired abdominal wall occurred three times (gunshot wound, appendectomy, cholecystectomy). Pain levels were low (median NAS = 0 at rest and under load). One recurrence was detected 8 months after primary repair in a liver transplant recipient reconstructed with a sandwich. Conclusion Primary and recurrent incisional hernia can be repaired durably based on biomechanical principles.

V-007 Robotic repair of a bilateral recurrent groin hernia in a kidney transplant patient

Abstract Aim Due to the increased frequency of kidney transplantations and the high incidence of inguinal hernia in men, the coincidence of both features is not uncommon. Material &amp; Methods A 58-year-old male patient with a history of a kidney transplantation in the right fossa due to bilateral shrivel kidneys, presented with a bilateral recurrent incisional hernia. Two years before he had an anterior bilateral groin hernia repair; a Liechtenstein repair on the left side and a partial preperitoneal repair with mesh reinforcement on the right side. Results The case was approached via a robot assisted TAPP (transabdominal preperitoneal) procedure to perform the preperitoneal dissection of the myopectineal orifices. At the region of the right inguinal hernia, the normal anatomy was distorted, due to the extraperitoneal course of the donor ureter which was freed accordingly. A partial mesh excision of the previous mesh was performed. The preperitoneal dissection area was covered with a self-gripping mesh. The postoperative course was uneventful. Conclusions The extraperitoneal course of the ureter in a kidney transplant patient challenges the surgical repair of an inguinal hernia. In primary groin hernias an anterior approach seems best suited, but in case of a recurrence after a previous anterior approach, a laparoscopic approach is a possible though challenging surgical option.

Long term outcomes of robotic-assisted abdominal wall reconstruction: a single surgeon experience.

Robotic abdominal wall reconstruction (RAWR) is one of the most significant advances in the management of complex abdominal wall hernias. The objective of this study was to evaluate long term outcomes in a cohort of patients that underwent complex RAWR in a single center. This was a longitudinal retrospective review of a cohort of 56 patients who underwent complex RAWR at least 24months prior by a single surgeon at a tertiary care institution. All patients underwent bilateral retro-rectus release (rRRR) with or without robotic transversus abdominis release (rTAR). Data collected include demographics, hernia details, operative and technical details. The prospective analysis included a post-procedure visit of at least 24months from the index procedure with a physical examination and quality of life survey using the Carolinas Comfort Scale (CCS). Patients with reported symptoms concerning for hernia recurrence underwent radiographic imaging. Descriptive statistics (mean ± standard deviation or median) were calculated for continuous variables. Chi-square or Fisher's exact test as deemed appropriate for categorical variables, and analysis of variance or the Kruskal-Wallis test for continuous data, were performed among the separate operative groups. A total score for the CCS was calculated and analyzed in accordance with the user guidelines. One-hundred and-forty patients met the inclusion criteria. Fifty-six patients consented to participate in the study. Mean age was 60.2years. Mean BMI was 34.0. Ninety percent of patients had at least one comorbidity and 52% of patients were scored ASA 3 or higher. Fifty-nine percent were initial incisional hernias, 19.6% were recurrent incisional hernias and 8.9% were recurrent ventral hernias. The mean defect width was 9cm for rTAR and 5cm for rRRR. The mean implanted mesh size was 945.0cm2 for rTAR and 362.5cm2 for rRRR. The mean length of follow-up was 28.1months. Fifty-seven percent of patients underwent post-op imaging at an average follow-up of 23.5months. Recurrence rate was 3.6% for all groups. There were no recurrences in patients that underwent solely bilateral rRRR. Two patients (7.7%) that underwent rTAR procedures were found with recurrence. Average time to recurrence was 23months. Quality of life survey demonstrated an overall CCS score of 6.63 ± 13.95 at 24months with 12 (21.4%) patients reporting mesh sensation, 20 (35.7%) reporting pain, and 13 (23.2%) reporting movement limitation. Our study contributes to the paucity of literature describing long term outcomes of RAWR. Robotic techniques offer durable repairs with acceptable quality of life metrics.

Evaluation of Darn Repair for Recurrence Rate in the Management of Indirect Inguinal Hernia

When an organ, or even part of an organ, protrudes through the inguinal canal, it is called an inguinal hernia. Two-thirds of all herniations are of the indirect inguinal subtype; they are most common in adults between 30 and 59; and men are twice as likely to be affected as women. The standard treatment for a hernia is surgery. A decrease in collagen metabolism and fibro-connective tissue in the groin is typically the root cause of an inguinal hernia. Both of these things cause the fascia transversalis to weaken. Because of this, surgeons have come up with a number of ways to strengthen the back wall of the inguinal canal. Methodology: Approximately 220 patients with indirect inguinal hernias participated in this descriptive study. The study collected data on the demographic characteristics of the patients, the clinical characteristics of the hernias, and the outcomes of the treatment. The results showed that the majority of the patients responded well to the treatment. The study also revealed that the incidence of hernia recurrence was low. Jinnah International Hospital Abbottabad and DHQ Battagram, Department of Surgery served as the study site for these individuals. Patients were followed for six months after therapy to check for problems or recurrence; darn repair was the modality of choice. Results: Results showed that darn repair had a low recurrence rate reported in the literature, despite some patients being lost to follow-up and others perceiving early complications like wound infection, seroma, hematoma formation, scrotal swelling, or prolonged postoperative pain. Restoring damaged tissues has also been shown to be less expensive than replacing damaged tissues with mesh. Tissue repair has showed potential and costs less than mesh repair for treating inguinal hernias, thus both options should be investigated. There is also a lower chance of infection with tissue repair compared to mesh repair Keywords: hernias,indirect inguinal hernia,darn repair,recurrence.