Intraperitoneal Mesh Placement Research Articles

Initial experience of SSI Mantra robot-assisted Transabdominal pre-peritoneal repair of primary ventral hernias.

Small and medium sized primary midline ventral hernias are best treated by pre-peritoneal mesh placement. This helps in prevention of complications related to intra-peritoneal mesh placement. The challenges we face while performing laparoscopic transabdominal pre-peritoneal (TAPP) procedure can be overcome by robot-assisted TAPP (rTAPP), and we present our initial experience with the same. We describe the surgical technique used in rTAPP using the relatively new SSI Mantra platform for primary midline ventral hernia repair and evaluate its feasibility and present the outcomes. we performed rTAPP for primary midline ventral hernia repair in 10 patients from July 2023 to September 2023. Demographic patient data, hernia characteristics and peri-operative outcomes were measured. A total of 10 patients underwent elective rTAPP for primary midline ventral hernia, of which 7 were male and 3 were female. The average defect size was 3.2 cm. The average operative time was 113 min. All the patients were discharged within 24-36 h after the procedure. There were no deaths. No post-operative complications such as haematoma, clinically significant seroma, deep or superficial wound infection or recurrence were noted within 30 days. rTAPP is a technically feasible procedure for the repair of small- and medium-sized midline ventral hernias with defect sizes up to 5 cm. SSI Mantra robotic platform provides the same benefit that other conventional robotic platforms provide at a much lesser cost. Further studies looking at the cost-benefit ratio are required to substantiate the above.

ENHANCED RECOVERY PATHWAY AFTER LAPAROSCOPIC HERNIOPLASTY IN PATIENTS WITH VENTRAL HERNIAS: IS IT NECESSARY TO APPLY?

The aim: To study the effectiveness of the enhanced recovery after surgery (ERAS) protocol for laparoscopic hernioplasty (LH) in patients with ventral hernias (VH).
 Materials and methods: 190 patients with VH after laparoscopic prosthetic hernioplasty with intraperitoneal mesh placement (IPOM) were included in the study and divided into two groups. The study group (ERAS group) included 92 (48.4%) patients to whom the ERAS protocol was applied, the control group (preERAS group) – 98 (51.6%) patients. The width of the hernia was more than 10 cm in 25 (13.2%) patients of the ERAS group. For them botulinum toxin type A (BTA) was injected into the muscles of the anterior abdominal wall 4 weeks before the operation. In the postoperative period, the duration of the operation, hospital length of stay, the intensity of the pain syndrome and well-being, the level of C-reactive protein (CRP) and interleukin-6 (IL-6) on the first postoperative day were evaluated.
 Results: After the introduction of BTA in 25 patients of ERAS group, the hernial defect decreased by an average of 4.6±0.62 mm and in all cases became less than 10 cm (р<0.001). The average duration of LH in the study and control groups did not differ statistically (ERAS; 91.2±37.41 min vs preERAS 88.9±30.05 min, p=0.76). In 2 hours after the operation, it was possible to activate all patients of the study group and 78 (79.6%) of the control group, within 4-6 hours – the other 20 (20.4%) patients of the control group. Using the ERAS protocol demonstrated significantly less intensity of pain syndrome according to visual analogue scale (VAS), complaints of nausea (р<0.001), bloating (р=0.017), feelings of hunger, thirst and general weakness (р<0.001). At the same time, there was no statistically significant difference in the presence of defecation (р=0.31). The average level of CRP after surgery was significantly higher in the control group compared to the study group (preERAS; 43.63 ± 13.90 vs ERAS; 16.55 ± 9.97, p<0.001). The level of IL-6 similarly increased more significantly in the control group (pre ERAS; 34.03 ± 18.18 vs ERAS; 11.44 ± 5.30, p<0.001). The length of hospital stay after surgery did not differ statistically between the groups (р=0.21).
 Conclusions: The use of the ERAS protocol during laparoscopic hernioplasty IРOM for patients with VH can reduce the intensity of the pain syndrome in the postoperative period and increase the patient's subjective assessment of their condition. The use of BTA in the preoperative period allows the implementation of the ERAS protocol even when used with large ventral hernias.

Hernia Recurrence and Complications After Abdominal Reconstruction With Reinforced Versus Nonreinforced Biologic Mesh.

Both biologic and permanent (synthetic) meshes are used for abdominal wall reconstruction. Biologic mesh has the advantage of eventual incorporation, which makes it generally preferred in contaminated patients compared with synthetic mesh (Ann Surg. 2013;257:991-996). However, synthetic mesh has been shown to have decreased long-term hernia recurrence despite increased complications (JAMA Surg. 2022;157:293-301). Ovitex (TelaBio, Ltd, Auckland, New Zealand) is a combined reinforced biologic mesh with a permanent Prolene suture weave that theoretically combines incorporation with a long-term strength component. We hypothesize that a reinforced biologic will have a similar complication profile but decreased long-term hernia recurrence. A single-center retrospective review was performed from January 2013 to January 2022. Baseline patient characteristics and outcomes including 90-day complications and recurrence were compared. Categorical and continuous variables were analyzed with χ2 and Wilcoxon rank sum tests, respectively. Predictors of postoperative complications and hernia recurrence were analyzed via univariate logistic regression and multivariate logistic regression with backward stepwise selection with a threshold of P < 0.2. Two hundred fifty-four patients underwent abdominal wall reconstruction biologic mesh (Strattice, Allergan; FlexHD, MTF Biologics; Alloderm, Allergan; Surgisis Gold, Cook Biotech; Ovitex, Telabio) with retrorectus (66.5%) or intraperitoneal (33.5%) mesh placement. Sixty-six of these used reinforced biologic mesh (Ovitex, TelaBio). Baseline characteristics were comparable including preoperative hernia size measured on CT. The mean follow-up time was 343 days. The majority of patients underwent component separation (80.3% bilateral, 11.4% unilateral, 8.3% none). On univariate analysis, reinforced biologic mesh did not impact 90-day complication rates (P = 0.391) or hernia recurrence rates (P = 0.349). On multivariate analysis, reinforced mesh had no impact on complication or recurrence rates (P > 0.2). A previous history of infected mesh was an independent risk factor for hernia recurrence (P = 0.019). Nonreinforced biologics were more likely to be used in instances of previous mesh infection (P = 0.025), bowel resection (P = 0.026), and concomitantly at the time of stoma takedown (P = 0.04). Reinforced biologics were more likely to be used with a history of previous hernia repair with recurrence not due to infection (P = 0.001). Body mass index >35 was an independent risk factor across both groups for 90-day complications (P = 0.028). Reinforced versus nonreinforced biologics have similar risk profile and recurrence rate when placed primary fascial repair achieved. In abdominal walls with history of infection, or abdominal wall reconstruction performed concomitantly at the time of stoma takedown or bowel resection/anastomosis, nonreinforced biologics were used more commonly with no difference in negative outcomes. This implies that they may have a role for use in contaminated surgical cases. Reinforced biologics were more commonly used as a mesh choice in the setting of previous hernia repair with recurrence with no difference in outcomes. This implies that the reinforced nature may be useful in situations where extra reinforcement of already traumatized abdominal wall tissue is needed. Retrorectus or intraperitoneal placement of any biologic mesh is acceptable and should be chosen based off surgeon comfort and anticipated cost saving of individual mesh brands. There may be a role for reinforced mesh in the setting of previous failed hernia repair with weakened fascia, as well as nonreinforced in contaminated cases.

The pros and cons of suturing the ventral hernia defect using the intraperitoneal onlay mesh technique

Background/Aim. Laparoscopic ventral hernia surgery, including intraperitoneal onlay mesh (IPOM), is as effective and safe as open surgery, with a lower recurrence rate. Some surgeons advocate laparoscopic primary fascial closure (PFC) with intraperitoneal mesh placement to reduce recurrence rates. The aim of this study was to compare the treatment outcome between two laparoscopic techniques: the PFC technique and mesh placement without suture closure (IPOM technique) for defects under 4 cm in patients with ventral hernias. Methods. The study sample was comprised of 50 patients who underwent laparoscopic ventral hernia surgery from January 1, 2018, until December 31, 2020. Half of the patients underwent only the IPOM technique (group of patients without the suture), while in others, this was preceded by the closure of the hernial ring (group of patients with the suture). All hernias were midline and all defects were under 4 cm. The studied groups were homogeneous according to gender and age. Comorbidities, complications, and postoperative comfort were monitored. Results. The most common (76%) hernias were primary, and the most common comorbidity was arterial hypertension (28%). One (2%) patient had intraoperative bleeding, and the most common postoperative complication was pain in 7 (14%) patients. After a threeyear follow-up, there were 10 (20%) patients with complications - one hernia recurred, while 9 (18%) patients died. There was no difference in the types of occurrence of hernias, comorbidities, and intraoperative complications. The distribution of postoperative complications differed significantly (p = 0.007) between the groups. Pain was statistically significantly more prevalent in patients with sutures. During the first three months postoperatively, significantly more patients with sutures had chronic pain (?2 = 8.140; p = 0.004). Conclusion. We recommend the application of the PFC technique in selected ventral hernia repair cases, although it can lead to more frequent postoperative pain (which, fortunately, is easily treated).

Tracheostomy in infants: Indications and outcomes

Background/Aim. Laparoscopic ventral hernia surgery, including intraperitoneal onlay mesh (IPOM), is as effective and safe as open surgery, with a lower recurrence rate. Some surgeons advocate laparoscopic primary fascial closure (PFC) with intraperitoneal mesh placement to reduce recurrence rates. The aim of this study was to compare the treatment outcome between two laparoscopic techniques: the PFC technique and mesh placement without suture closure (IPOM technique) for defects under 4 cm in patients with ventral hernias. Methods. The study sample was comprised of 50 patients who underwent laparoscopic ventral hernia surgery from January 1, 2018, until December 31, 2020. Half of the patients underwent only the IPOM technique (group of patients without the suture), while in others, this was preceded by the closure of the hernial ring (group of patients with the suture). All hernias were midline and all defects were under 4 cm. The studied groups were homogeneous according to gender and age. Comorbidities, complications, and postoperative comfort were monitored. Results. The most common (76%) hernias were primary, and the most common comorbidity was arterial hypertension (28%). One (2%) patient had intraoperative bleeding, and the most common postoperative complication was pain in 7 (14%) patients. After a three-year follow-up, there were 10 (20%) patients with com-plications ? one hernia recurred, while 9 (18%) patients died. There was no difference in the types of occurrence of hernias, comorbidities, and intraoperative complications. The distribution of postoperative complications differed significantly (p = 0.007) between the groups. Pain was statistically significantly more prevalent in patients with sutures. During the first three months post-operatively, significantly more patients with sutures had chronic pain (?2 = 8.140; p = 0.004). Conclusion. We recommend the application of the PFC technique in selected ventral hernia repair cases, although it can lead to more frequent postoperative pain (which, fortunately, is easily treated).

Technical aspects of performing laparoscopic hernioplasty in the treatment of large ventral hernias

Laparoscopic hernioplasty is a promising treatment option for ventral hernias. The technique of intraperitoneal mesh placement (IPOM) is the most extensively studied and widely used for the closure of a defect during laparoscopic hernia repair. The large size of the defect and its diameter exceeding 10 cm are limiting factors in the selection of minimally invasive techniques for hernioplasty. The process of suturing the hernia prior to the placement of the mesh, as well as the technique used to fix it, show controversial results in terms of postoperative quality of life and the risk of recurrence. Objective — to study the technical aspects of performing laparoscopic prosthetic hernioplasty using the IРOM technique for the surgical treatment of patients with large primary ventral hernias (PVH) and postoperative incisional ventral hernias (IVH). Materials and methods. The study included a total of 84 patients who were undergoing treatment at the clinical base of the Department of General Surgery No. 2 of Bogomolets National Medical University. There were 51 (60.7%) women and 33 (39.3%) men. The average age was 58.73±10.9 years. All patients were operated on for large ventral hernias. Of these, 52 (61.9%) patients had surgery for PVH (umbilical hernia, line alba hernia), while 32 (38.1%) — for IVH. In 56 (66.7) patients, the width of the hernia defect was &gt; 10 cm, of which 24 (28.6%) patients had PVH. In these patients, 4 weeks before surgery, 100 units of botulinum toxin type A (BTA) were injected intramuscularly into the muscles of the anterior abdominal wall in accordance with the methodology developed in the clinic. All patients underwent laparoscopic prosthetic hernioplasty with IPOM under general combined anesthesia. Control examinations of patients were carried out 2 weeks, 1 month, 6 months, and 1 year after the operation. Results. All patients underwent IPOM, while 38 (45.2%) patients underwent laparoscopic IPOM with suturing of the defect, 36 (42.9%) patients underwent IPOM with suturing the hernia defect before placing the mesh (IPOM+), and 10 (11.9%) patients underwent IPOM without suturing the defect. 32 (38.1%) patients were aged 65 years, including 10 patients who did not undergo suturing of the defect before the mesh placement. After the injection of BTA, the number of patients with a defect width of ≥10 cm decreased to 15 (17.8%). All of these patients had a defect smaller than 15 cm. The average duration of surgery for IPOM without hernia suturing was 60.00±11.30 min; for IPOM with laparoscopic suturing, it was 108.16±40.29 min; for IPOM+ with open suturing, it was152.08±40.64 min. The average length of stay in the hospital after surgery was higher in the group of patients who underwent hernioplasty using the IPOM+ technique compared to other techniques (p &lt;0.001). In the early postoperative period, the complication rate was 13.1%; all cases were classified as minor (Grade I, II, IIIa) according to the Clavien–Dindo classification. Conclusions. Laparoscopic hernioplasty using the IPOM is a safe and reliable method for large ventral hernia repair. Administering preoperative BTA injections enables the reduction of the defect and facilitates the execution of laparoscopic hernioplasty in patients with a primary hernia size of ≥10 cm.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a 5–10-year follow-up of the randomized controlled multicenter study

PurposeIn this long-term follow-up of a prospective, randomized, and multicenter study, we compare the results of a group receiving laparoscopic incisional ventral hernia repair using intraperitoneal onlay mesh (LG) to a group receiving a hybrid hernia repair where open closure of fascial defect was added to intraperitoneal mesh placement (HG).MethodsOriginally, 193 patients with 2–7 cm incisional hernias were randomly assigned to either the LG or HG during the 30-month recruitment period in 2012 to 2015. Long-term follow-up was conducted 5–10 years after surgery to evaluate hernia recurrence rate and quality of life (QoL).ResultsIn all, 65 patients in the LG and 60 in the HG completed the long-term follow-up with a median follow-up period of 87 months. Recurrent hernia was detected in 11 of 65 patients (16.9%) in the LG and 10 of 60 patients (16.7%) in the HG (p > 0.9). Kaplan–Meier analysis demonstrated a recurrence rate approaching 20% in both groups, with similar curves. Three patients in the LG (4.6% and five patients in the HG (8.1%) had undergone re-operation due to recurrence (p = 0.48). There was no difference in patient-reported QoL measured using the SF-36 questionnaire. Mean pain scores were similar between groups, mean numeric rating scale (NRS) 0 to 10 being 1.1 in the LG and 0.7 in the HG (p = 0.43).ConclusionFascial closure did not reduce hernia recurrence rate in this study population, even though it has been shown to be beneficial and recommended in surgery guidelines. In the long term, recurrence rate for both groups is similar.

Transabdominal retro muscular versus intraperitoneal onlay mesh repair of ventral hernia: a randomized controlled study

Background Although laparoscopic ventral hernia repair has become a well-established alternative for open repair, traditional intraperitoneal mesh placement in direct contact with the bowel had many drawbacks and complications; in addition, it requires extensive mesh fixation and special composite mesh. Using the peritoneum and posterior rectus sheath as a barrier between the mesh and the bowel will evade these complications and decrease the cost. Patients and methods This prospective study was conducted in between May 2022 and December 2022 on 50 patients with noncomplicated ventral hernia with an average defect size of 5 cm. Patients were randomly allocated into two groups: intraperitoneal onlay mesh (IPOM) group (25) patients and transabdominal retro muscular mesh (TARM) group (25) patients. Both groups were compared as regards preoperative demographics, intraoperative complications and operative time and postoperative outcomes and complications. Results With a mean age of (44.96±7.27) of IPOM and (48.92±7.17) of TARM group, a significant longer operative time was spent in TARM repair (108.40±9.43 min). Postoperative pain was less in patients with TARM repair and hence they had earlier recovery and restoration of daily activities. Using a double-face composite mesh made the cost of IPOM repair significantly higher than TARM (P &lt; 0.001). Overall postoperative complications and recurrence rate showed no significant difference between both techniques. Conclusion TARM repair seems to be a safe and good alternative to IPOM repair in terms of lower economic cost and less postoperative pain.

Robotic-Assisted Totally Extraperitoneal (eTEP) Hernia Repair with a Suprapubic Approach for Umbilical and Epigastric Hernias: A Retrospective Study

Abstract Background In the treatment of umbilical and epigastric hernias, during the last years were developed robotic-assisted techniques to avoid intraperitoneal mesh placement. Robotic-assisted transabdominal preperitoneal (eTAPP) and totally extraperitoneal (eTEP) were described and studies reported that both techniques were safe and achieved optimal results. However, no evidence is reported regarding the best technique. Aims The aim of our study was to assess the safety and effectiveness of the robotic-assisted eTEP compared to eTAPP with suprapubic trocar insertion to treat umbilical and epigastric hernias. Methods We selected from a prospectively maintained database patients who underwent robotic-assisted umbilical and epigastric hernia repair with a suprapubic approach, either eTEP or eTAPP. We retrieved clinical and follow-up data and a statistical analysis was carried out. Results During the study period, 53 patients were included. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). Operative time was slightly shorter for eTEP than eTAPP (106 ± 43 min vs. 126 ± 74 min, p=0.232). No intraoperative complications occurred. Postoperatively, only a case of bleeding and a seroma were recorded. The length of follow-up was 11.3 ± 6.4 months in the eTEP group vs. 20.5 ± 9.7 months in the eTAPP group and no case of recurrence, chronic pain, or significant dysesthesia was recorded. Conclusions In our study, we found that the eTEP approach to treat epigastric and umbilical hernias was safe and feasible and achieved excellent perioperative and follow-up results. The outcomes were similar to patients undergoing the eTAPP approach, but with the advantages of a shorter operative time and not entering the peritoneum.

Short-term Outcomes After Laparoscopic IPOM Versus Robot-assisted Retromuscular Repair of Small to Medium Ventral Hernias: A Nationwide Database Study.

To examine the short-term outcomes after laparoscopic intraperitoneal onlay mesh (IPOM) compared with robot-assisted retromuscular repair of small to medium-sized ventral hernia. With the introduction of a robot-assisted approach, retromuscular mesh placement is technically more feasible compared with laparoscopic IPOM, with potential gains for the patient, including avoidance of painful mesh fixation and intraperitoneal mesh placement. This was a nationwide cohort study of patients undergoing either laparoscopic IPOM or robot-assisted retromuscular repair of a ventral hernia with a horizontal fascial defect <7 cm in the period 2017 to 2022, matched in a 1:2 ratio using propensity scores. Outcomes included postoperative hospital length of stay, 90-day readmission, and 90-day operative reintervention, and multivariable logistic regression analysis was performed to adjust for the relevant confounder. A total of 1136 patients were included for analysis. The rate of IPOM-repaired patients hospitalized > 2 days was more than 3 times higher than after robotic retromuscular repair (17.3% vs. 4.5%, P < 0.001). The incidence of readmission within 90 days postoperatively was significantly higher after laparoscopic IPOM repair (11.6% vs. 6.7%, P =0.011). There was no difference in the incidence of patients undergoing operative intervention within the first 90 days postoperatively (laparoscopic IPOM 1.9% vs. robot-assisted retromuscular 1.3%, P =0.624). For patients undergoing first-time repair of a ventral hernia, robot-assisted retromuscular repair was associated with a significantly reduced incidence of prolonged length of postoperative hospital stay and risk of 90-day readmission compared to laparoscopic IPOM.

OC-101 PLACEMENT OF INTRAPERITONEAL PREFORMED PROPHYLACTIC MESH IN END COLOSTOMIES TO REDUCE PARASTOMAL HERNIA AND COMPARING WITH CONTROL GROUP. TECHNIQUE AND ANALYSIS OF OUR RESULTS

Abstract Objective To study the effect of the incidence of parastomal hernia (PSH) through the prophylactic placement of a preformed intraperitoneal mesh in patients who must undergo a definitive colostomy. The comparison is made with a homogeneous control group that did not receive prophylactic mesh. Material and methods Unicentric, prospective, non-randomized and observational study was performed. Patients were divided in two groups: 30 patients with colorectal neoplastic disease, collected consecutively,who underwent an end colostomy with a profilactic preformed intraperitoneal mesh (Dynamesh IPST®) versus a homogeneous control group (30 patients) who also underwent a definitive end colostomy without prophylactic mesh placement. Primary objective is to determine incidence of PSH in both groups. Secondary objectives were mesh related complications. Demographic variables and early postoperative complications, clinical and radiological follow-up (18–24 months) and presence of clinical and/or radiological PSH were registered. The surgical technique performed in our center is described. Results In the Mesh group there were 0 mesh-related complications at 30 days. In the long term, only 6.6% PSH were recorded in mesh group, while in the control group, a 63% of PSH were observed. Conclusions The incidence of PSH is significantly reduced using prophylactic mesh. Our study corroborates what has already been stated in the literature and does not associate complications. The prophylactic placement of the IPST intraperitoneal mesh in patients who require a definitive end colostomy is a technique that is easy to use in the laparoscopic approach, safe, fast, and easily reproducible, without related complications.

OC-012 NATIONWIDE ANALYSIS OF SHORT-TERM OUTCOMES AFTER LAPAROSCOPIC IPOM VS. ROBOT-ASSISTED RETROMUSCULAR REPAIR OF SMALL TO MEDIUM VENTRAL HERNIA

Abstract Aim With the introduction of a robot-assisted approach, retromuscular mesh placement is technically more feasible compared to laparoscopic IPOM, with potential gains for the patient, including avoidance of painful mesh fixation and intraperitoneal mesh placement. We aimed to examine the short-term outcomes after laparoscopic intraperitoneal onlay mesh (IPOM) compared to robot-assisted retromuscular repair of small to medium sized ventral hernia. Material &amp; Methods This was a nationwide cohort study of all patients undergoing either laparoscopic IPOM or robot-assisted retromuscular repair of a ventral hernia with a horizontal fascial defect &amp;lt;7 cm in the period 2017 to 2022. Outcomes included postoperative hospital length of stay, 90-day readmission, and 90-day operative reintervention, and multivariable logistic regression analysis was performed to adjust for the relevant confounder. Results A total of 2,453 patients were included for analysis, of which 389 patients underwent robot-assisted retromuscular hernia repair and 2,064 laparoscopic IPOM repair. The rate of IPOM repaired patients hospitalized more than 2 days was 4 times higher than after robotic retromuscular repair (18.2% vs. 4.5%, P &amp;lt; 0.001). The incidence of readmission within 90 days postoperatively was significantly higher after laparoscopic IPOM repair (10.9% vs. 6.7%, P = 0.016). There was no difference in the incidence of patients undergoing operative intervention within the first 90 days postoperatively (laparoscopic IPOM 1.8% vs. robot-assisted retromuscular 1.3%, P = 0.579). Conclusions Robot-assisted retromuscular ventral hernia repair was associated with a significantly reduced incidence of prolonged length of postoperative hospital stay and risk of 90-day compared to laparoscopic IPOM.

Evaluation of Treatment Differences Between Men and Women Undergoing Ventral Hernia Repair: An Analysis of the Abdominal Core Health Quality Collaborative

INTRODUCTION: Sex is emerging as an important clinical variable associated with surgical outcomes and decision-making. Its impact on baseline and treatment differences in primary and incisional ventral hernia repair remains unclear. METHODS: This retrospective cohort study uses the Abdominal Core Health Quality Collaborative (ACHQC) database to identify elective umbilical, epigastric, or incisional hernia repair. Propensity matching was performed to investigate confounder-adjusted treatment differences between men and women. Treatments of interest included surgical approach, mesh use, mesh type, mesh position, anesthesia type, myofascial release, fascial closure, and fixation use. RESULTS: A total of 8,489 umbilical, 1,801 epigastric, and 16,626 incisional hernia repairs were identified. Women undergoing primary ventral hernia repair were younger (umbilical 46.4 vs 54 years, epigastric 48.7 vs 52.7 years), with lower BMI (umbilical 30.4 vs 31.5, epigastric 29.2 vs 31.1), and less likely diabetic (umbilical 9.9% vs 11.4%, epigastric 6.8% vs 8.8%). Women undergoing incisional hernia repair were also younger (mean 57.5 vs 59.1 years), but with higher BMI (33.1 vs 31.5), and more likely diabetic (21.4% vs 19.1%). Propensity analysis included 3,644 umbilical, 1,232 epigastric, and 12,480 incisional hernias. Women with incisional hernia were less likely to undergo an open repair (60.2% vs 63.4%, p < 0.001) and have mesh used (93.8% vs 94.8%, p = 0.02). Women had a higher rate of intraperitoneal mesh placement, and men had a higher rate of preperitoneal and retromuscular mesh placement. CONCLUSION: Small but statistically significant treatment differences regarding operative approach, mesh use, and mesh position exist between men and women undergoing ventral hernia repair.

Evaluation of Treatment Differences Between Men and Women Undergoing Ventral Hernia Repair: An Analysis of the Abdominal Core Health Quality Collaborative.

Sex is emerging as an important clinical variable associated with surgical outcomes and decision making. However, its relevance in regard to baseline and treatment differences in primary and incisional ventral hernia repair remains unclear. This is a retrospective cohort study using the Abdominal Core Health Quality Collaborative database to identify elective umbilical, epigastric, or incisional hernia repairs. Propensity matching was performed to investigate confounder-adjusted treatment differences between men and women. Treatments of interest included surgical approach (minimally invasive or open), mesh use, mesh type, mesh position, anesthesia type, myofascial release, fascial closure, and fixation use. A total of 8,489 umbilical, 1,801 epigastric, and 16,626 incisional hernia repairs were identified. Women undergoing primary ventral hernia repair were younger (umbilical 46.4 vs 54 years, epigastric 48.7 vs 52.7 years), with lower BMI (umbilical 30.4 vs 31.5, epigastric 29.2 vs 31.1), and less likely diabetic (umbilical 9.9% vs 11.4%, epigastric 6.8% vs 8.8%). Women undergoing incisional hernia repair were also younger (mean 57.5 vs 59.1 years), but with higher BMI (33.1 vs 31.5), and more likely diabetic (21.4% vs 19.1%). Propensity-matched analysis included 3,644 umbilical, 1,232 epigastric, and 12,480 incisional hernias. Women with incisional hernia were less likely to undergo an open repair (60.2% vs 63.4%, p < 0.001) and have mesh used (93.8% vs 94.8%, p = 0.02). In umbilical and incisional hernia repairs, women had higher rates of intraperitoneal mesh placement and men had higher rates of preperitoneal and retro-muscular mesh placement. Small but statistically significant treatment differences in operative approach, mesh use, and mesh position exist between men and women undergoing ventral hernia repair. It remains unknown whether these treatment differences result in differing clinical outcomes.

Spontaneous Migration of Intraperitoneal Mesh into Rectum following Ventral Hernia Repair

AbstractWe present a rare case of spontaneous migration of mesh into the anal canal 6 years after laparoscopic intraperitoneal mesh placement for ventral hernia. Mesh migration is an uncommon phenomenon with an unclear etiology and is probably attributed to prolonged subclinical infection or foreign body reaction. This is probably the first case in literature to our knowledge, where composite mesh was migrated into the anal canal after a laparoscopic intraperitoneal mesh placement and was retrieved in a natural way without surgical intervention.

Primary closure of the midline abdominal wall defect during laparoscopic ventral hernia repair: analysis of risk factors for failure and outcomes at 5 years follow-up.

The primary aim of this prospective study is to report bulging and recurrence rates and to analyze the risk factors responsible for failure, after laparoscopic ventral hernia repair (LVHR) with primary closure of defect (PCD) using a running suture and intraperitoneal mesh placement, at 5-year follow-up. The secondary endpoint is to evaluate 30-day postoperative complications, seroma, and pain. PCD failure was defined as the presence of postoperative bulging and/or recurrence. Pain was evaluated using a visual analogue scale (VAS). After surgery, fifty-eight patients underwent clinical examination and computed tomography scan to diagnose bulging, recurrence, and seroma (classified according to the Morales-Conde classification). At 60months follow-up, recurrence was observed in five patients (8.6%), while bulging, not needing a surgical treatment, occurred in fifteen patients (25.9%). Chronic obstructive pulmonary disease (COPD) is the only risk factor responsible for both outcomes together, bulging and recurrences (p = 0.029), while other considered risk factors as gender, age, body mass index, diabetes, smoke habits, primary or incisional hernia and the ratio defect width/transverse abdominal axis did not achieve the statistically significance. Clinical seroma was diagnosed at one month in eight patients (13.8%). Seromas were observed at one year of follow-up. During the follow-up, pain reduction occurred. LVHR has evolved toward more anatomical concepts, with the current trend being the abdominal wall anatomical reconstruction to improve its functionality, reducing seroma rates. Based on results obtained, PCD is a reliable technique with excellent recurrence rate at 5years follow-up, even when the defect closure may generate tension at the midline. On the other hand, this tension could be related with high bulging rate at long-term, particular in case of patients with COPD.

Complications of Intraperitoneal Mesh Techniques for Incisional Hernia - A Systematic Review.

Incisional hernia is considered to be one of the most frequent complication of abdominal surgery, with an incidence up to 20% or 35-50%. Given the latest focus on laparoscopic approach of any surgical pathology, there is a tendency in managing the incisional hernias in this particular manner, which impose intraperitoneal onlay mesh placement (IPOM). The aim of this review is to gather more information regarding the possible complications that can be associated with this technique. The study was conducted based on a bibliographic research using the databases: PubMed, Scopus and Web of Science. The work was reported in line with PRISMA guidelines. The study conducted shows that the short-term risks of intraperitoneal mesh placement for incisional hernia repair are not life-threatening and are comparable to other prosthetic surgical techniques. The most frequent complications can be devided in minor: seroma, hematoma and recurrent pain, and major: enterocutaneous fistula, mesh infection and Adhesions-Bowel obstruction. The high rate of unavailability for follow-up, especially regarding major complications that usually occur after a significant period of time, limits the results of the studies documented and they lack the quality-of-life assessment.

P135 ESTABLISHMENT OF MINIMALLY INVASIVE VENTRAL HERNIA REPAIR WITH EXTRAPERITONEAL MESH PLACEMENT AS A STANDARD APPROACH OF VENTRAL HERNIA REPAIR USING THE ROBOTIC PLATFORM

Abstract Aim Several meta-analyses indicated, that extraperitoneal mesh placement in the retromuscular or preperitoneal space shows advantages over intraperitoneal mesh placement. Previous surgical interventions which included extraperitoneal mesh placement were usually performed using open surgery. For several years now, our hospital has pursued to treat ventral hernias using a minimally invasive approach with extraperitoneal mesh placement. A Da Vinci X system has been available since the beginning of 2019. The aim of this analysis is to show the process of changing the operative procedure in ventral hernia repair over the period from 2016 to 2020. Material and Methods All hernia operations from 2016-2020 were evaluated using our hospitals information system. Every surgical intervention which included ventral hernia repair with the indication for mesh implantation was taken into the analysis. Results In 2016, the proportion of minimally invasive procedures was 36.67%. In all of these cases an intraperitoneal mesh was implanted in the abdominal cavity (laparoscopic IPOM operation). Open surgery was performed in 63.33%, out of which we implanted an intraperitoneal mesh in 23.68%, a retromuscular mesh in 73.68% and an onlay mesh in 2.63% of the cases. In 2020, the proportion of minimally invasive operations was already 87.5%, of which 83.33% were performed robotically assisted and 16.67% laparoscopically. In 94.29% of the minimally invasive operated patients an extraperitoneal mesh implantation was carried out, among which 75.76% were placed in the retromuscular and 24.24% in the preperitoneal position. Conclusions The majority of elective operations on ventral hernias can be performed in a minimally invasive technique with retromuscular mesh placement, using the robot.

P049 SAFETY AND EFFICACY OF ABSORBABLE AND NON-ABSORBABLE FIXATION SYSTEMS FOR INTRAPERITONEAL MESH FIXATION: AN EXPERIMENTAL STUDY IN SWINE

Abstract Aim Choice of the best fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of this study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation. Material and Methods Fourteen Landrace swine were utilized and the experiment included two stages. Initially, four pieces of polypropylene mesh with hydrogel barrier coating1 were fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. Each mesh was anchored with a different tack device between titanium2, steel3 or absorbable (4,5) fasteners. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy. The primary endpoint was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks. Results Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Steel tacks had higher peel strength when compared to titanium and absorbable fasteners. No significant differences were noted regarding the secondary endpoints. Conclusions Steel fasteners provided higher peel strength that the other devices in this swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

P031 OPEN VERSUS LAPAROSCOPIC INCISIONAL HERNIA REPAIR: A NATIONWIDE DATABASE STUDY

Abstract Aim Although laparoscopic repair of incisional hernias decreases the incidence of wound complications as compared with open repair, there has been a rising concern related to intraperitoneal mesh placement. The aim of this study was to examine outcomes after open or laparoscopic elective incisional hernia mesh repair on a nationwide basis. Material and Methods A merge of data between the Danish Hernia Database and the National Patient Registry provided data on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence from 2007-2018. Results A total of 3,090 (57.5%) and 2,288 (42.5%) patients were operated by laparoscopic and open approach, respectively. The defect was closed in 27.9% (865/3,090) of the laparoscopic cases. The median follow-up time was 4.0 (1.8-6.8) years. Rates of readmission (16.2%, 502/3,090) and re-operation for complication (7.0%, 216/3,090) were significantly lower for laparoscopic compared to open repairs (19.3%, 442/2,288, P = 0.003 and 12.5%, 288/2,288, P &amp;lt; 0.001). Re-operation for bowel obstruction or bowel resection was twice as high after laparoscopic repair (0.6%, 20/3,090) compared with open repair (0.3%, 6/2,288, P = 0.044). Patients were significantly less prone to undergo repair of recurrence following laparoscopic compared with open repair of defect widths 2-6 cm (P = 0.002). Conclusions Laparoscopic intraperitoneal mesh repair for incisional hernia should still be considered for fascial defects between 2 and 6 cm, because of decreased incidences of early complications and repair of hernia recurrence compared with open repair.