Large Hernia Research Articles

Open Versus Thoracoscopic Repair of Congenital Diaphragmatic Hernia: A 19-Year Review in a Tertiary Referral Centre in Hong Kong

BackgroundCongenital diaphragmatic hernia (CDH) is a developmental defect that causes herniation of abdominal organs into the thoracic cavity with significant morbidity. Thoracoscopic repair of CDH is an increasingly prevalent yet controversial surgical technique, with limited long-term outcome data in the Asian region. The aim of this study was to compare open laparotomy versus thoracoscopic repair of CDH in paediatric patients in a major tertiary referral centre in Asia. MethodsWe performed a retrospective analysis of neonatal patients who had open laparotomy or thoracoscopic repair for CDH in our institution between July 2002 and November 2021. Demographic data, perioperative parameters, recurrence rates and surgical complications were analysed. Results64 patients were identified, with 54 left sided CDH cases. 33 patients had a prenatal diagnosis and 35 patients received minimally invasive surgical repair. There was no significant difference between open and minimally invasive repair in recurrence rate (13 % vs 17 %, P = 0.713), time to recurrence (184 ± 449 days vs 81 ± 383 days, P = 0.502), or median length of ICU stay (11 ± 14 days vs 13 ± 15 days, P = 0.343), respectively. Gastrointestinal complications occurred in 7 % of neonates in the open group and none in the thoracoscopic group. Median follow-up time was 9.5 years. ConclusionsThis study is a large congenital diaphragmatic hernia series in Asia, with long term follow-up demonstrating no significant difference in recurrence rate, time to recurrence or median length of ICU stay between open and minimally invasive repair, suggesting thoracoscopic approach is a non-inferior surgical option with avoidance of gastrointestinal complications compared to open repair. Level of Evidence3. Type of StudyRetrospective Cohort Study.

Large spontaneous lung hernia—a case report

Abstract Intercostal lung hernias can be results of trauma or surgery. True spontaneous lung hernias thought to be a result of sudden acute increase in intrathoracic pressures are extremely rare. Only 51 cases have been reported in literature over the past four-and-half decades. We report a case of spontaneous chest wall posterior-lateral lung herniation that developed in a 73-year-old following severe coughing and straining during an episode of lower respiratory tract infection. Herein we present the unusual findings in the case and outline the pathophysiology of the problem and management options available.

Long-term pulmonary outcome of children with congenital diaphragmatic hernia: functional lung MRI using matrix-pencil decomposition enables side-specific assessment of lung function

ObjectivesIn patients with congenital diaphragmatic hernia (CDH) the exact functional outcome of the affected lung side is still unknown, mainly due to the lack of spatially resolved diagnostic tools. Functional matrix-pencil decomposition (MP-) lung MRI fills this gap as it measures side-specific ventilation and perfusion. We aimed to assess the overall and side-specific pulmonary long-term outcomes of patients with CDH using lung function tests and MP-MRI.MethodsThirteen school-aged children with CDH (seven with small and six with large defect-sized CDH, defined as > 50% of the chest wall circumference being devoid of diaphragm tissue) and thirteen healthy matched controls underwent spirometry, multiple-breath washout, and MP-MRI. The main outcomes were forced expiratory volume in 1 second (FEV1), lung clearance index (LCI2.5), ventilation defect percentage (VDP), and perfusion defect percentage (QDP).ResultsPatients with a large CDH showed significantly reduced overall lung function compared to healthy controls (mean difference [95%-CIadjusted]: FEV1 (z-score) −4.26 [−5.61, −2.92], FVC (z-score) −3.97 [−5.68, −2.26], LCI2.5 (TO) 1.12 [0.47, 1.76], VDP (%) 8.59 [3.58, 13.60], QDP (%) 17.22 [13.16, 21.27]) and to patients with a small CDH. Side-specific examination by MP-MRI revealed particularly reduced ipsilateral ventilation and perfusion in patients with a large CDH (mean difference to contralateral side [95%-CIadjusted]: VDP (%) 14.80 [10.50, 19.00], QDP (%) 23.50 [1.75, 45.20]).ConclusionsData indicate impaired overall lung function with particular limitation of the ipsilateral side in patients with a large CDH. MP-MRI is a promising tool to provide valuable side-specific functional information in the follow-up of patients with CDH.Clinical relevance statementIn patients with congenital diaphragmatic hernia, easily applicable MP-MRI allows specific examination of the lung side affected by the hernia and provides valuable information on ventilation and perfusion with implications for clinical practice, making it a promising tool for routine follow-up.Key Points• Functional matrix pencil decomposition (MP) MRI data from a small sample indicate reduced ipsilateral pulmonary ventilation and perfusion in children with large congenital diaphragmatic hernia (CDH).• Easily applicable pencil decomposition MRI provides valuable side-specific diagnostic information on lung ventilation and perfusion. This is a clear advantage over conventional lung function tests, helping to comprehensively follow up patients with congenital diaphragmatic hernia and monitor therapy effects.

OGBN P24 Primary symptom indication can be a predictor of outcomes in revisional anti-reflux surgery

Abstract Background Symptom recurrence after primary hiatus hernia surgery is an established problem and revision anti-reflux surgery may be indicated in select cases of recurrence after primary surgery. Previous studies on this subject are of small number and often lack objective measures. Our aim is to assess the relationship between primary symptom indication and a variety of objective and subjective post operative outcomes. Methods A prospectively maintained single surgeon database of revisional hiatus hernia surgery from 1992 to 2022 was retrospectively evaluated. This was a consecutive cohort of adults greater than 18 years of age. The symptomatic, anatomical, and physiological indications for surgery were reviewed. The symptoms described by patients were grouped into four categories: typical reflux, volume, obstructive and gastric motility symptoms. The intraoperative findings and post operative outcomes were analysed. The dataset consisted of 379 patients, of whom 59% were female. The average age of this cohort at the time of primary revisional surgery was 59 years (range 19-91). Results Intraoperative findings of the revision operations found that 32% had a large hiatus hernia, 30% had a small hernia, 16% had a moderate hernia, 8% had a very large hernia. Patients who initially presented with volume symptoms appeared more likely to have two or more revision operations than patients who presented with no volume symptoms. Symptom score improvement was seen in reflux and dysphagia symptoms following revisional surgery. No significant improvement was seen in volume symptoms. Symptom focused questions in the GIQLI score demonstrated a statistically significant improvement in dysphagia symptoms 12 months post surgery (p=0.021). Conclusions Patients presenting initially with volume symptoms may be more likely to require multiple revision operations. This could be either due to an undiagnosed underlying motility disorder or advanced severity at presentation. Consideration of an alternative procedure such as roux-en-y gastric bypass could be entertained in this group.

OGBN P29 Short term outcomes after anti-reflux surgery for Gastro-Oesophageal Reflux disease

Abstract Background Laparoscopic fundoplication is the standard surgical practice for management of Gastro-oesophageal reflux Disease (GORD). However, post operative complications and recurrence can be problematic. We conducted this study to assess short-term post operative outcomes following anti-reflux surgery (ARS) for GORD at our UGI surgery unit at a busy District General Hospital (DGH). Methods All patients above 18 years of age undergoing ARS between January 2016 and December 2021 were included. We excluded patients who underwent fundoplication as part of treatment of achalasia or large hiatus hernia repairs. Data was collected retrospectively from a prospectively maintained database. Pre –operative investigations and surgical procedure was recorded. Primary outcome assessed were post-operative complications recorded as per Clavien-Dindo grade and re-operation rates. Secondary outcomes assessed were symptomatic relief and proton pump inhibitor (PPI) discontinuation. Results 86 patients were included. The median age at surgery was 52 years. 98% patients had typical symptoms of GORD at presentation. On pre-operative OGD, 29% patients had oesophagitis and 77.91% had hiatus hernia. 79 (91.86%) patients underwent pH manometry. 97.67% patients underwent Nissen fundoplication. All cases were successfully completed laparoscopically with no conversions to open. The median post-operative length of stay was 1 day. 93.02% had no post operative complications, and none had 30 day re-operation. At 1-year follow up, 97.67% patients reported improvement in symptoms and 94.19% patients were able to stop PPI use. Conclusions Laparoscopic fundoplication provides excellent relief of GORD symptoms with low incidence of post operative complications and re-operation rates.

OGBN O08 The Safety and Efficacy of Laparoscopic Hiatus Hernia Repair with Biosynthetic Mesh (Phasix-ST®): A Single Centre Experience

Abstract Background Surgical management of large hiatus hernia (> 5 cm defect) remains challenging due to high recurrence rates. Mesh augmentation in laparoscopic hiatal hernia repair has been used to reduce recurrences but carries risks such as mesh erosion, contraction, infection, and reaction to the foreign body. Introducing biosynthetic meshes offers a promising adjunct to primary suture repair of hiatal defects with enhanced tissue integration and reduced risk of infection. Phasix™ ST mesh is a biosynthetic mesh made of Poly-4-Hydroxybutyrate (P4HB). This study evaluates early patient outcomes following laparoscopic hiatal hernia repair with Phasix™ ST mesh, including its safety and efficacy profile. Methods This study was to evaluate outcomes of laparoscopic hiatus hernia repair using Phasix™ ST mesh in adult patients (>18 years) at our institution. All patients undergoing this procedure between September 2020 to April 2023 were identified from a prospectively maintained database. Our standardised technique involved on-lay crural reinforcement with Phasix™ ST mesh after primary closure of the hiatal defect, followed by partial fundoplication. Patient records were reviewed retrospectively to assess these end-point measures: postoperative mortality and morbidity at 30 days, functional results reported during the follow-up period, and recurrence rates of hiatus hernia. Results Conclusions This is the first study in the United Kingdom demonstrating that laparoscopic hiatus hernia repair with the use of Phasix™ ST mesh for crural reinforcement has low-rate complications, with most patients reporting symptom improvement and discontinuing PPI use in the early-term follow–up. Further long-term studies are needed to validate these findings.

Effects of Spinal Deformities on Hiatal Hernia Occurrence and Recurrence

BackgroundSpinal deformities such as kyphosis, lordosis, and scoliosis have demonstrated a possible association between these deformities. Our hypothesis is that the presence of spinal deformities will increase the risk of hiatal hernia recurrence after repair. MethodsThe following data was retrospectively gleaned for patients undergoing hiatal hernia repair (1997–2022): age, sex, date of hiatal hernia repair, presence and type of spinal deformity, Cobb angle, type of hiatal hernia and size, type of hiatal hernia repair, recurrence and size, time to recurrence, reoperation, type of reoperation, and time to reoperation. ResultsSpinal deformities were present in 15.8% of 546 patients undergoing hiatal hernia repair, with a distribution of 21.8% kyphosis, 2.3% lordosis, 58.6% scoliosis, and 17.2% multiple. There was no difference in sex or age between groups. Spinal deformity patients were more likely to have types III and IV hiatal hernias (52.3% vs. 38.9%, p = 0.02) and larger hernias (median 5 [3-8] vs. 4 [2-6], p = 0.01). There was no difference in access, fundoplication use, or mesh use between groups. However, these patients had a higher recurrence rate (47.7% vs 30.0%, p = 0.001) and a shorter time to recurrence (months) (10.3 [5.6-25.1] vs 19.2 [9.8-51.0], p = 0.02). Cobb angle did not affect recurrence. ConclusionsSpinal deformity patients were more likely to have more complex and larger hiatal hernias. They were at higher risk of hiatal hernia recurrence after repair with shorter times to recurrence. This is a group that requires special attention with additional preoperative counseling and possibly use of surgical adjuncts in repair.

A Comparison of Outcomes of the Component Separation Techniques in Large Incisional Hernias: Mesh vs. No Mesh

A Comparison of Outcomes of the Component Separation Techniques in Large Incisional Hernias: Mesh vs. No Mesh

A morbidly obese patient with large incisional hernia managed with posterior compartment separation sub-lay mesh placement

Most of the incisional hernias are diagnosed in first 3 years after the major abdominal surgery but some may take 9-10 years before the presentation after surgery. Risk factors to develop incisional hernia includes patient factors; advanced age, hypertension, diabetes, obesity, anemia, smoking, chronic obstructive pulmonary disease (COPD), immunosuppression, previous coronary intervention, renal disease requiring dialysis, recent weight loss and malnutrition. Surgery related risk factors includes intraoperative complication, suture technique, surgical site infections, fascial dehiscence and other postoperative complications. We are presenting of large incisional hernia, which have managed with posterior compartment separation. Large incisional ventral hernias following abdominal surgeries can pose significant challenges in management and quality of life for both patients. The Rives-Stoppa repair technique provides authentic and essential solution for management of large complex ventral hernias with reducing the risk of recurrence and providing long-term support to the abdominal wall.

Late presentation Bochdalek hernia complicated by mesentero-axial volvulus

A 5 year old with a history of recurrent chest infections and presumed asthma presented to the emergency department with acute severe abdominal pain, tachycardia and pallor. Chest radiograph done to exclude pneumoperitoneum demonstrated a large gas filled structure occupying the majority of the left hemithorax. This was superimposed with several tubular gas filled structures. CT showed a large left-sided diaphragmatic hernia of the Bochdalek type containing the pancreas, stomach, small bowel loops, small bowel mesentery with vessels and lymph nodes and some large bowel. Associated left pulmonary hypoplasia was present. In addition, the stomach was significantly dilated with an ‘upside down’ configuration. It’s antrum and pylorus were above the diaphragm and gastro-oesophageal junction while its fundus and proximal body were below the diaphragm, appearances in keeping with mesentero-axial volvulus, necessitating urgent surgical management.

Robotic repair of a large chronic traumatic diaphragmatic hernia

Robotic repair of a large chronic traumatic diaphragmatic hernia

Endoscopic impedance planimetry versus high-resolution manometry (HRM) for pre-operative motility evaluation in anti-reflux surgery.

Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study. Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant. Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3kg/m2. Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001). Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for GERD.

Technique and outcomes of robotic-assisted retroperitoneal radical nephrectomy.

Robotic retroperitoneal partial nephrectomy (rRPN) has numerous advantages over transperitoneal surgery, including direct access to the renal hilum and posterior tumors, and avoidance of the peritoneal cavity in patients with a hostile abdomen. Although the use of the retroperitoneal approach has increased over the last decade, there is little literature on robotic retroperitoneal radical nephrectomy (rRRN), which has similar benefits over the transperitoneal approach. The aim of this study was to describe our technique for robotic retroperitoneal nephrectomy (rRN) and assess its feasibility and outcomes at a high-volume center. A retrospective review of patients who underwent some form of rRN [rRRN, robotic retroperitoneal simple nephrectomy (rRSN), or robotic retroperitoneal nephroureterectomy (rRNU)] at a single institution between 2013 and 2023. Patient characteristics, operative data, and postoperative complication rates were assessed. The technique for rRN was detailed. A total of 13 renal units in 12 patients were included for analysis (7 rRRN, 5 rRSN, 1 rRNU). Median patient age was 64.0 years, and median body mass index (BMI) was 36.0 kg/m2. Indications for retroperitoneal surgery were prior abdominal surgery in all patients, including three with bowel diversions, super morbid central obesity in two patients, and a large ventral hernia in one patient. Median operative time was 213 minutes and median estimated blood loss (EBL) was 85 cc. Median postoperative length of stay (LOS) was 3 days, and only one patient experienced a Clavien-Dindo grade ≥3 complication within 90 days of surgery. The retroperitoneal approach for robotic-assisted nephrectomy is feasible and associated with similar outcomes as the transperitoneal approach. This approach may prove beneficial in select patients with significant prior abdominal surgery including those who are morbidly obese.

Dysphagia and oesophageal dilation in giant hiatus hernia: angulation of the gastro-oesophageal junction or achalasia?

The co-existence of achalasia and large para oesophageal hernia (PEH) is uncommon. The anatomical disruption of the GOJ mechanism by hiatal herniation may result in chronic angulation and secondary partial oesophageal obstruction. A unique case is described where the diagnostic uncertainty of coexistant achalasia and PEH with angulation causing chronic oesophageal obstruction existed. This case highlights the importance of multimodality workup of oesophageal disorders utilising endoscopy, fluoroscopy and manometry. Accurate identification of physiological abnormalities allowed appropriate design of operative intervention.

Transversus abdominis release with biosynthetic mesh for large ventral hernia repair: a 5-year analysis of clinical outcomes and quality of life.

Transversus abdominis release (TAR) may provide an optimal plane for mesh placement for large ventral hernias requiring medial myofascial flap advancement. Long-term outcomes of TAR for large ventral hernia repair (VHR) remains under-studied. This study aims to assess longitudinal clinical outcomes and quality of life (QoL) following large VHR with TAR and resorbable biosynthetic mesh. Retrospective review of clinical outcomes and prospective QoL was performed for patients undergoing VHR with poly-4-hydroxybutyrate mesh and TAR from 2016 to 2021. Patients with ≤ 24months of follow-up, defects ≤ 150cm2, and parastomal hernias were excluded. Cost-related data was collected for each patient's hospital course. QoL was compared using paired Wilcoxon signed-rank tests. Twenty-nine patients met inclusion criteria. Median age and BMI were 61years (53.2-68.1years) and 31.4kg/m2 (26.1-35.3kg/m2). Average hernia defect was 390cm2 ± 152.9cm2. All patients underwent previous abdominal surgery and were primarily Ventral Hernia Working Group 2 (58.6%). Two hernia recurrences (6.9%) occurred over the median follow-up period of 63.1months (IQR 43.7-71.3months), with no cases of mesh infection or explantation. Delayed healing and seroma occurred in 27 and 10.3% of patients, respectively. QoL analysis identified a significant improvement in postoperative QoL (p < 0.005), that continued throughout the 5-year follow-up period, with a 41% overall improvement. Cost analysis identified the hospital revenue generated was approximately equal to the direct costs of patient care. Higher costs were associated with ASA class and length of stay (p < 0.05). Large VHR with resorbable biosynthetic mesh and TAR can be performed safely, with a low recurrence and complication rate, acceptable hospital costs, and significant improvement in disease-specific QoL at long-term follow-up.

MEsh FIxation in Laparoendsocopic Repair of Large M3 inguinal hernias: multicenter, double-blinded, randomized controlled trial—study protocol for a MEFI Trial

BackgroundInternational guidelines of groin hernia treatment strongly recommend to fixate the mesh in large M3 medial defects during TAPP/TEP procedures. The main purpose of fixation is to decrease the recurrence rate which is alarmingly high in case of those defects. In 2022, a team consisting of hernia surgeons and scientists from universities of technology conducted an experimental study with the use of 3D groin model to verify the hypothesis that fixation is not necessary in above cases. Experiment showed that rigid and anatomically shaped meshes are able to maintain its position in the groin without fixation. Similar conclusions were recently published in Swedish database registry analysis. To confirm above results, we decided to conduct a multicenter randomized controlled trial.MethodsMain objective of MEFI Trial is to verify the hypothesis that non-fixation of spatial, standard polypropylene meshes is non-inferior to fixation of flat, polypropylene lightweight meshes in M3 hernias by laparoendoscopic approach. Eleven large surgery centers in Poland having proficiency in laparoendoscopic groin hernia repairs were recruited for this study. Recurrence in 12-month follow-up was set as a primary endpoint. Pain sensation (Visual Analog Scale) and incidence of other complications (hematoma, seroma, SSI) were also noted. Based on the statistical analysis, minimal sample size in both arms was established at 83–102. The first arm (control) consists of patients undergoing a repair with the use of a flat, macroporous mesh with fixation using histoacryl glue. In the second arm, patients will be operated with the use of anatomically shaped, standard-weight mesh without fixation. Study will be double-blinded (patient/surgeon). After the dissection of preperitoneal space, surgeon will open a sealed envelope and find out which technique he will have to perform. Follow-up will be performed by Study Secretary (also blinded to the method used) via phone call 3 and 12 months after surgery.DiscussionBased on experimental study and recent registry analysis, we believe that the recurrence rate in both groups would be on the same level, giving hernia societies a strong argument for amending the guidelines.Trial registrationClinicalTrials.gov NCT05678465. Registered on 10 January 2023.

TAR (Trans versus Abdominis Muscle Release) - A Novel Approach for Large Ventral Hernia: Case Report

TAR (Trans versus Abdominis Muscle Release) - A Novel Approach for Large Ventral Hernia: Case Report

Incidentally Diagnosed Large Asymptomatic Morgagni Hernia in Adult Male Patient.

Congenital diaphragmatic hernias are rare congenital defects resulting in abdominal organ protrusion into the thoracic cavity; they mainly present with pulmonary or gastrointestinal symptoms. Although congenital and discovered in utero or in early childhood, they can be asymptomatic for a long time and even remain asymptomatic despite the growing hernia sac dimensions and the hernia sac contents. We present a case of a 58-year-old patient with incidentally diagnosed Morgagni hernia during the COVID-19 pandemic following a computerised tomography (CT) scan of the chest. He presented without any symptoms related to the existence of the hernia. Another CT scan was performed 20 months after the initial diagnosis to evaluate the progression of the hernia. The patient refused the offered surgery due to the absence of symptoms. A Morgagni hernia is usually discovered during pregnancy or in early childhood, but sometimes can be asymptomatic for years. Main symptoms originate from the respiratory and gastrointestinal system. Due to the refusal of surgery, we were able to follow the CT scan enlargement progression of patients' hernia over a 20-month period. Congenital diaphragmatic Morgagni hernias can remain undiscovered for a long period of time.Despite the usual clinical presentation with pulmonary and/or gastrointestinal symptoms, it can be asymptomatic in some patients.Surgery is the recommended treatment for a Morgagni hernia (via the thoracic or abdominal access).

483. INTRAOPERATIVE EVALUATION OF HIATAL HERNIA SIZE AND CANDIDACY IN TIF ELIGIBLE PATIENTS

Abstract Background Transoral incisionless fundoplication (TIF) is gaining prominence in treatment of gastroesophageal reflux disease (GERD) for patients with absent or small hiatal hernia. As TIF gains popularity, appropriate patient evaluation and selection is paramount in establishing anatomical candidacy hence successful outcome. We evaluated patients who were intended to be treated with TIF and underwent a standard evaluation but instead underwent robotic hiatal hernia repair. We compared their preoperative evaluation of hernia size with intraoperative findings. Methods A cohort of seventy-six patients from a single-center database from January 2020 to March 2023 were retrospectively analyzed. All were deemed candidates for TIF based on our inclusion criteria (pH confirmation of GERD, hiatal hernia &amp;lt;2 cm) and underwent preoperative testing with endoscopy, esophagram, pH and manometry. Twenty-seven of these patients either were denied TIF by their insurance company or had personal preference for surgery (daVHH) over endoscopic intervention and underwent robotic assisted paraesophageal hernia repair. We examined intraoperative measurements of hiatal hernia size and EG junction anatomy and compared them to standard preoperative evaluation. Results On pre-operative endoscopy 23 patients were found to have no hiatal hernia, 20 were found to have a small hernia, 3 a medium hernia, and 1 a large hernia. Esophagram evaluation demonstrated no hiatal hernia in 17 patients and a small hernia in 23 patients. The average hiatal hernia size seen during manometry was 0.54 cm (0–2 cm) while the average hernia seen intra-operatively was 3.26 cm (1.5–4.8 cm). There was a significant difference between preoperative hernia size evaluated by manometry and intraoperative hernia size (p-value 0.04). Conclusion Standard preoperative evaluation of patients intended to be treated with TIF appears to have a tendency to underestimate the size of hiatal hernia and omits evaluation of paraesophageal anatomy. This can lead to poor patient selection of failure of this treatment modality. Addition of cross-sectional imaging to the evaluation of patients with small hiatal hernias can facilitate a more meaningful therapeutic decision making for endoscopic, surgical, and combination treatment options.

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

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