Large Incisional Hernias Research Articles

OC-064 CHOICE FOR ANTERIOR VERSUS POSTERIOR COMPONENT SEPARATION IN INCISIONAL HERNIA REPAIR IS IMPORTANT REGARDING POSTOPERATIVE COMPLICATIONS

Abstract Aim Both anterior component separation technique (aCST) and posterior Transversus Abdominis Release (TAR) are valuable techniques, but the limits for using these techniques are unclear. The aim is to compare outcomes regarding postoperative wound morbidity and recurrence for both techniques. Methods A retrospective analysis of prospectively collected data was carried out. Patients with any form of component separation technique, aCST or TAR, between 3/2013 and 8/2022 were included. Data was analyzed for patient demographics, risk factors, surgical site occurrences(SSO), general complications and hernia recurrence. Follow up was performed at 1 month, 1 year and 2 years. Results A total of 258 patients underwent CST: 68 (26.4%) aCST and 190 patients (73.6%) TAR. Patients showed no significant difference for gender, risk factors and comorbidities. The aCST group showed larger defects (EHS-W3 in 64.7% vs. 45.3%, p=0.006). Intrahospital complications were lower in the TAR group (12.1% vs 29.4%, p=0.001). SSO rate at one month was significantly lower in the TAR group (12.7% vs 43.9%, p<0.001) with SSO- procedural interventions 6.3% vs 30.3%, p<0.001). Recurrence was low in both groups (aCST 3.0% vs TAR 1.6%). Follow up was complete in 93.8% of patients. Conclusion Although aCST and TAR are both valid options in large incisional hernia repair, postoperative wound morbidity as well as overall complication rates are significantly increased after aCST. It seems indicated to choose TAR over aCST in laterally located hernia defects and in large midline defects and only consider aCST in case of doubt about complete anterior fascial closure.

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.

USE OF TANAKA INDEX IN PLANNING OF PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM (PPP) FOR THE REPAIR OF GIANT INCISIONAL HERNIAS WITH LOSS OF DOMAIN IN A TERTIARY CARE HOSPITAL

BACKGROUND AND OBJECTIVES :Incisional hernia is the most common iatrogenic malady. Not only does it lead to complications, aesthetic problems and a prolonged disability, there is also the problem of recurrences. Incisional hernias occur in 2–15% of patients who undergo laparotomy, with recurrence rates after treatment of 0–46%. In this study, we have used the Tanaka index in planning of preoperative pneumoperitoneum for the repair of large incisional hernias with loss of domain. METHODS: In this study, all patients with large incisional hernias with loss of domain who were admitted to surgical wards of McGann District Teaching Hospital, attached to Shimoga Institute of Medical Sciences during the study period of 18 months (01/01/2021 to 30/06/2022) are included. After satisfying inclusion and exclusion criteria, these patients have been thoroughly examined, investigated and evaluated preoperatively and subjected to pre operative progressive pneumoperitoneum (PPP) and subsequently to various surgical repairs. Follow up post operatively has been done for a maximum of 6 months after discharge. RESULTS: Incidence of Incisional hernias was more in females with male to female ratio of 1.7:1. On an average, 10 PPP sessions were needed and the volume of air inated was 4000ml (average) .Rives stoppas repair with left Transverse abdominis release repair was performed in maximum cases. We received good results with healthy wound status post 6 months of surgery. CONCLUSION For large incisional hernias with LOD, PPP and the use of TANAKA Index has been found to be useful with excellent results

ONLAY VERSUS RIVES-STOPPA TECHNIQUES IN THE TREATMENT OF INCISIONAL HERNIAS.

In the surgical correction of large incisional hernias, the use of a prosthesis is essential in most cases regardless of the technique chosen. The preference is for the polypropylene prosthesis. To compare the onlay and Rives-Stoppa techniques in the correction of incisional hernias, their immediate results, complications, advantages, and disadvantages. Two groups of patients with incisional hernias were analyzed, submitted to the onlay (19 patients) and Rives-Stoppa (17 patients) techniques, and that used polypropylene prostheses. General epidemiological variables, perioperative data variables, and postoperative complications were assessed. The patients' epidemiologic profile was similar between both groups. The majority were women (58.4%), with a mean age of 65.5 years and a previous mean body mass index of 41.5 kg/m². The Rives-Stoppa technique was employed in most patients (52.7%). Those submitted to the onlay technique had longer abdominal drainage time and longer hospital stay, as well as a higher incidence of seromas and surgical wound infection. The incisional herniorrhaphy technique with the placement of a pre-peritoneal polypropylene mesh by the Rives-Stoppa technique was superior to the onlay due to lower rates of drain use, hospital stay, and postoperative complications.

Comparison of Surgical Treatment Results of Large Incisional Hernias.

Introduction Incisional hernias are one of the most common complications after abdominal surgery. Surgical repairs of large incisional herniashave higher complications and recurrence rates compared to smallerincisional herniarepairs. For this reason, it is a more difficult and experience-requiring application for surgeons. In addition, there is no evidence-based consensus in the literature regarding the optimal surgical treatment of large incisional hernias.The aim of this study is to compare the results of the three most common surgical treatment methods used ina tertiary university hospital for the repair of large incisional hernias in terms of patients' characteristics, recurrence, and complication rates of the treatment methods. Methods Between 2014 and 2020, 366 patients with incisional hernias with facial defects larger than 10 cm in a tertiary medical faculty hospital located in eastern Turkey were analyzed.Patients were divided into three groups according to the surgical method used: open onlay prolene mesh(OPM) method, laparoscopic intraperitoneal sublay dual mesh (IPSDM) method, and open IPSDM method. Postoperative complications were divided into five groups as follows: wound complications, complications due to surgical procedures, medical complications, recurrences, and mortality. Treatment methods were compared according to the demographic characteristics of the patients and the postoperative complication rates. Results Of the patients, 141 were male and 225 were female, and the mean age was 58.0 ± 28 years. Of the patients,81.9% were operated on with the open OPM, 10.9% with the laparoscopic IPSDM, and 7.1% with the open IPSDM.Wound complications occurred in 26.7% of patients, surgical complications in 3.2%, medical complications in 6.5%, recurrence in 9.2%, and mortality in 0.8% of patients.Total wound complications were significantly higher in the open OPM group (30%) (p = 0.009). Total surgery complications were significantly higher in the laparoscopic IPSDM group (15%) (p = 0.002). There was no significant difference between groups for medical complications (p = 0.540). Although no recurrence was observed in the open IPSDM group, no significant difference was observed between the groups(p = 0.099). There was no difference in mortality rates between the groups (p = 0.450). The overall complication rate was highest in the open OPM group (48.3%) and lowest in the open IPSDM group (27%) (p = 0.092).The operative time was found to be significantly shorter in open IPSDM (p < 0.001). The length of hospital stay was highest in the open OPM group and lowest in the open IPSDM group (p = 0.450). Conclusions Although hernia defect is greater in the open IPSDM compared to other methods, this method is more advantageous in terms of the complication rate associated with the surgical procedure, the overall complication rate, the duration of surgery, and the recurrence rate. Laparoscopic IPSDM is a more advantageous method in terms of the overall wound and medical complications.

Hernia Sac Preservation for Prevention of Transversus Abdominis Release in Laparoscopic Extended-Totally Extra Peritoneal Repair of Ventral Hernia: A Minimalistic Solution for a Formidable Challenge.

Background: Ventral hernia repair has always been an extensive and challenging surgery. The laparoscopic extended-Totally Extraperitoneal (E-TEP) technique of ventral hernia repair is gaining popularity due to the advantage of placing a large mesh in the retro rectus plane. When done through a Laparoscopic approach, the difficulty of the procedure is compounded by multiple factors such as obtaining retro muscular access, maintaining the retro muscular plane, crossing over to the contralateral retro muscular plane without entering intraperitoneally, suturing in a limited space, and manipulation of a large mesh in a constricted space for placement. In cases of large midline incisional hernias, dense adhesions to the previous surgical scar are often present. Despite having extremely satisfying outcomes, the aforementioned factors make the laparoscopic extended-total extraperitoneal repair of large midline ventral and incisional hernias an exceptionally challenging procedure. A tension-free midline approximation is the benchmark of ventral/incisional hernia surgery. In certain cases, this can be difficult to achieve due to multiple factors. For the purpose of attaining tension-free midline closure, component separation techniques (CST) have been explored and implemented. Of these, the posterior component separation technique of Transversus Abdominis Release (TAR) has gained popularity for reducing the tension of posterior rectus sheath during posterior midline closure in retro muscular repairs by adding a few centimetres of medial advancement. The main pitfall of TAR is its technical complexity, which may result in morbid complications when implemented incorrectly. Performing TAR laparoscopically compounds the complexity manyfold. Hence, to obviate the necessity to perform Laparoscopic TAR in cases of Laparoscopic E-TEP repair of large midline ventral and incisional hernias, we present that the technique of hernial sac preservation should be pre-emptively carried for all Laparoscopic ETEP repairs so that the necessity of performing TAR in select cases is reduced by aiding in the addition of final crucial centimetres of lengthening to the posterior rectus sheath for achieving posterior midline closure. This aids in the success of the procedure by preventing an additional complex procedure of TAR from being performed in an already challenging hernia repair technique of Laparoscopic E-TEP repair. Methods: We hereby report three cases of Ventral hernia repair in which Laparoscopic E-TEP repair was carried out and Hernial sac preservation technique was implemented successfully. Midline closure of the posterior rectus sheath was attained under reduced tension and a medium-weight macroporous polypropylene mesh was placed in the retro-rectus plane after measurement of the potential space. Patients were discharged uneventfully. Results: Patients were followed up for up to 6months postoperatively and were found to have no complications. Conclusion: In Laparoscopic E-TEP repair of midline ventral hernias, preservation of the hernial sac along with the posterior rectus sheath might aid in the prevention of performing a TAR in selected cases where posterior layer tension is present. Hernia sac preservation thereby aids in reducing operative time and preventing potential morbid complications.

Botulinum Toxin Use for Abdominal Wall Reconstruction

INTRODUCTION: Preoperative botulinum toxin (BTX) injection may assist in fascial closure of large incisional hernia repair. We examine outcomes of incisional hernia patients who receive BTX injections before abdominal wall reconstruction (AWR). METHODS: A retrospective cohort study of patients from 2019–2021 who underwent BTX abdominal wall injections and interval AWR was conducted. A matched cohort who underwent IH repair without BTX treatment was selected for comparable defect size and BMI. Clinical and demographic data were extracted from charts. RESULTS: Twenty patients received BTX injections, and 30 comparable patients did not. There was no difference in average age (58.6 and 61.4 years, p = 0.514), BMI (32.9kg/m2 and 32.4kg/m2, p = 0.813), or defect size (663.9 cm2 and 608.43 cm2, p = 0.513). Primary outcome of fascial closure was achieved in every patient in the BTX group (20 of 20) vs 86.7% (26 of 30) in the non-BTX group (p = 0.089). The BTX group had a lower rate of component separation (65.0% of the BTX group vs 93.3%, p = 0.01). The BTX group had higher rates of seroma (p = 0.03) and longer surgery time, 4:07 vs 3:58 (p < 0.01). The postoperative period had one dehiscence (non BTX group). There was no difference in incidence of surgical site infection, abscess, delayed healing, respiratory failure, pulmonary embolism, acute kidney injury, or length of stay. CONCLUSION: Patients receiving botulinum toxin injections into their abdominal wall musculature achieved greater rates of closure with good outcomes. We conclude that botulinum toxin injection for large incisional hernias is an effective method for relaxation of abdominal wall muscle and closure of large abdominal wall.

P-077 SURGICAL TREATMENT OF LARGE INCISIONAL HERNIA WITH BOTULINUM TOXIN A INJECTION: STUDY PROTOCOL FOR A DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL

Abstract Aim The best strategy for W3 incisional hernia (IH) repair is not known to date and is associated with high risks of recurrence and morbidity. We aim to demonstrate that preoperative Botulinum Toxin A (BTA) injection in the lateral abdominal wall muscles reduces the rate of postoperative morbimortality after large IH (EHS W3) repair with mesh, compared with placebo injection. Material &amp; Methods This study will be a prospective, national multi-center, double-blinded, randomized (1:1) superiority phase III trial with two parallel arms: BTA versus placebo injection. Participants will be selected based on an abdomino-pelvic CT-scan without contrast injection performed in the 6 months preceding the patient's surgery. Main inclusion criteria will comprise midline anterior primary or recurrent IH (subxiphoidal to suprapubic), of width ≥ 10 cm, without loss of domain. Patients included will be randomized (1: 1 ratio), by using a computer-generated randomization scheme, and randomization will by stratified on the center and width of the IH (10–15 cm and &amp;gt; 15 cm). Participants will be randomized on the day of the injection, at least 4 weeks before the surgery. Results The primary endpoint will be the occurrence of Clavien-Dindo classification grade II or higher post-operative complication during the 90-day postoperative period. Secondary endpoints will include the rates of primary fascial closure, occurrence of component separation techniques, radiological response to injections, consumption of analgesics and pain, and occurrence of clinical and radiological recurrences. Conclusions Protocol version 2.0 is currently being assessed for funding by the French Ministry of Health.

P-150 TRANSVERSUS ABDOMINIS RELEASE BY MINIMAL INVASIVE SURGERY. OUR EXPERIENCE IN A TERCIARY HOSPITAL

Abstract Aim We present the experience in the transversus abdominis release (TAR) technique using a minimally invasive approach in our center. Methods We expose those W3 defects intervened by laparoscopic TAR(n=6). Step 1: Releasing adhesions from previous surgeries. Step 2: Bilateral Rives space dissection, as well as the Rossen's space, this one using “down to up” technique. Step 3: Closure of the gap with barbed suture. In all cases, a PVDF mesh has been associated with atraumatic fixation, and 2 drains were placed. Results The mean age was 62, 100% men, and their BMI was greater than 25Kg/m2. All underwent scheduled surgery, using a minimally invasive approach, placing the mesh at the retromuscular level. Postoperative stay was 7.6 days. We did not obtain major complications (perforation, bleeding), but a drainage hole wound infection was registered. We had no readmissions or any medical complications. Follow-up of 12 months, without signs of recurrence or chronic pain. Conclusions Although Robotic surgery and Botulinum toxin in surgery seems to be the future, in our experience TAR technique performed by laparoscopy is useful for large midline incisional hernias treatment as well as those associated with a lateral component in a terciary Hospital. We obtain good results in terms of recurrence and restoration of the abdominal wall dynamics. However, further studies are necessary to be carried out by experienced teams to reach conclusions.

P-004 OUR EXPERIENCE WITH POSTERIOR COMPONENT SEPARATION – TAR (TRANSVERSUS ABDOMINIS RELEASE) IN LARGE COMPLEX INCISIONAL HERNIAS – A SERIES OF 18 PATIENTS

Abstract Background Large incisional hernias represent a challenge for parietal surgeon. Thanks to the modification of the Rives-Stoppa technique introduced by Novitsky, a new era in solving complex defects begun. Posterior component separation (PCS) with unilateral/bilateral TAR has promising results in many studies. Our experience is presented in a retrospective study. Method We present a study on 18 patients (sex ratio=1:1), operated between 2019–2022, with large complex incisional hernias. Mean body mass index was 37.17 kg/m2 (range 31–42). Mean age – 58 years (range 34–70 years). We used PCS with bilateral TAR in 12 cases (66.66%) and unilateral TAR in 6 cases. One of the hernias was a combined midline-large parastomal hernia operated using Pauli technique. 5 of the hernias (27.78%) were lumbar, of which 2 were operated with hybrid technique (open and laparoscopic), using reverse TAR. Mesh used was polypropylene (61.11%) and ePTFE mesh (38.89%). The prothesis size ranged from 20×25 cm to 34×32 cm. Mean operative time was 3.41 hrs (range 2–4 hrs). Average hospitalization time was 5.44 days (range 2–14 days). Results Fascial closure anterior to mesh was achieved in 72.22% of patients. No recurrences were reported in the follow-up (3–12 months). Postoperative morbidity: seromas (33.33%), wound infection (11.11%), hematoma (5.55%). Conclusions Rives-Stoppa technique is the gold standard in VHR. Extending this technique with PCS-TAR in complex incisional hernias seems to be the perfect solution in obese patients with great outcome and low postoperative morbidity. Also the hybrid approach has great results and we hence recommend.

P-127 E-TEP ASSISTED REVERSE-TAR FOR THE TREATMENT OF LARGE LUMBAR INCISIONAL HERNIAS ASSOCIATED TO MIDLINE DEFECTS

Abstract Aim To describe a new hybrid surgical approach of large lumbar incisional hernias (IH) associated to synchronic midline defects. Material and Methods Prospective multicentric study including patients with large lumbar hernias (L4W3) associated to midline abdominal wall defects. Surgical intervention starts with a bilateral retrorectus dissection performed through a minimally invasive extraperitoneal endoscopic approach (eTEP). Once this space has been dissected, the lumbar IH is treated with an overextended centrifugal preperitoneal open approach through the previous lumbar incision. Afterwards the dissected spaces are communicated performing a reverse transversus abdominis release (TAR) from lateral to medial. A prosthetic preperitoneal repair is performed with an absorbable and permantent meshes that cover the space dissected. Results Five patients were included in the study. All patients had lumbar hernias L4W3 associated to primary or incisional midline hernias M1–5 W1–2. Eighty percent of the patients were women, with a mean age of 62 years. Mean BMI was 32 (range 30–34), with a 60% of diabetic patients, and 80% of recurrent lumbar hernias (between 1 and 3 previous repair attempts). Mean surgical time was 198 minutes (range 160–250). Mean hospital stay was 5 days (range 4–8 days). Two lumbar hematomas which didn't required any interventional procedure took place as the only surgical site occurrences, without any systemic complications. No recurrence has taken place after 5 months mean follow up (range 2–9 months) Conclusion Hybrid eTEP and open approach of large lumbar hernias associated with small midline defects seem to be an efficient and safe approach.

P-022 USE OF SEPRAFILM ADHESION BARRIER® IN COMPLEX LARGE INCISIONAL HERNIA

Abstract Aim The short-term results of the use of seprafilm® as a reinforcement of the peritoneum are presented. Material and Methods Seprafilm® was used in 5 patients with large midline and lateral incisional hernia in which Transversus Abdominis Release Technique was performed in which it was necessary to explant mesh previously. This weakness of the peritoneum was reinforced with the seprafilm® plates, to isolate the intra-abdominal contents from the mesh. Results The patients treated had an average stay of 6.6 days. All of them carried drains. There were no infectious complications in surgical site. There were no prolonged pain. All of them began tolerance the day after the surgery. At one month of the surgical intervention, there were no signs of infection, seroma or higher pain than 3 on the EVA scale. Discussion Post-operative adhesions to mesh are related to intestinal fistulas. The use of preperitoneal space to place the mesh is a good option, although sometimes it can have continuity problems, especially when there are explants of previous materials. The use of barrier materials is appropriate in these cases. Conclusion The use of Seprafilm® can be a good option as a barrier between viscera and prostheses for the prevention of adhesions.

V-049 E-TEP RIVES-STOPPA AND OPEN REVERSE TRANVERSUS ABDOMINIS RELEASE (TAR): A HYBRID APPROACH FOR LARGE LATERAL-INFERIOR INCISIONAL HERNIAS

Abstract Aim To present hybrid approach with open/endoscopic extraperitoneal dissection for large lateral-inferior incisional hernias Material and Methods 64 years-old man who underwent left laparoscopic nephrectomy (2019) due to hypernephroma with specimen extraction by a left oblique iliac incision. He presents L3–4 W3 incisional hernia (14×10 cm) Technique description Results After 48 hours ICU admission patient was discharged to hospital ward. Drainages were removed at 2nd-4thpostoperative day and hospital stay was 5 days. Conclusion The hybrid approach to large lateral incisional hernias allowed us to use a large sublay mesh with an increased overlap beyond the hernia defect, trying to reduce hernia recurrence rate.

P-138 PREDICTORS OF COMPLICATIONS IN COMPLEX VENTRAL HERNIA REPAIR USING POSTERIOR COMPONENT SEPARATION TECHNIQUE WITH RETRO RECTUS MESH PLACEMENT – AN OBSERVATIONAL STUDY

Abstract Introduction Incisional Hernia has an incidence ranging from 2–20%. Large and complex incisional hernias are difficult to treat with standard procedures. PCS-TAR is a relatively novel procedure. There persists a gap in knowledge regarding its outcomes, especially in the Indian population. Aims &amp; Objective To identify the pre-operative clinical and radiological factors that predict the risk of re-herniation and wound and mesh-related complications after CVH (Complex Ventral Hernia) Methodology In a prospective observational study, patients undergoing open PCS-TAR with retro rectus mesh for Complex Ventral Hernia repair included in the study. The patient demographics, hernia characteristics, radiological details, operative data, post- operative outcomes, and follow-up data were entered in a pre-designed proforma. Data were analyzed with SPSS softwere. Results 35 patients with CVH were included, of which 30 (85%) women and 5 men. The mean age was 51.8 years and the mean BMI was 29.7 kg/m2. The mean size of defect was 12 cm. 83% hernia were midline primary and 255 were recurrent hernias. We observed zero recurrences at six months of follow-up, but a high wound morbidity rate of up to 49%, of which most common was seroma formation. 23% of patients developed SSI. Conclusion In conclusion, PCS-TAR is a promising novel procedure for complex ventral hernias not amenable to primary closure using the traditional retro rectus approach, with excellent short term outcomes. Wound morbidity is a significant concern with this procedure, which can be prevented or reduced by thorough pre-operative optimization on a case-to-case basis.

The outcome of pre-operative botulinum toxin in the treatment of large incisional hernias

Large incisional hernias with loss of domain represents a challenge for the surgeon. Pre-operative tools such as progressive pneumoperitoneum or botulinum toxin type A have been reported as useful tools for effective and successful surgical procedure in patients with large incisional hernias. Both the mentioned procedures are complementary to hernia repair, using no-strain mesh techniques that support patients’ integral management. The objective of current investigation was to assess the potential of pre-operative botulinum toxin in the treatment of large incisional hernias. Thirteen patients with large incisional hernias were investigated and examined for different parameters including diameters of the abdominal cavity and hernia sac, volume of the contents of incisional hernia and volume of the abdominal cavity which were calculated from CT scan. The current investigation was carried for a duration of two years from December 2020 and January 2022. After thorough clinical examination patients were operated for ventral incisional hernia repair. Eleven patients underwent complete repair of abdominal wall; one patient underwent mesh bridging and one patient required onlay repair. Botulinum toxin was observed to be a safe technique, which has good patient tolerance and can constitute as an effective preoperative tool in the treatment of large incisional hernia. This technique was observed to be aidful in significantly reducing the hernia content into the abdominal cavity, which in turn is an important factor in the treatment of large incisional hernia.

Effect of preoperative, high-dose glucocorticoid on early cognitive function after abdominal wall reconstruction – A randomized controlled trial

IntroductionPreoperative high-dose glucocorticoid (GC) improves postoperative recovery and reduces length of stay but increases the risk of postoperative cognitive dysfunction (POCD). Whether preoperative high-dose GC increases the risk of POCD in abdominal wall reconstruction (AWR) is unknown. Material and methodsThis was a double-blind randomized controlled trial examining the effect of 125 mg methylprednisolone (MP) iv versus placebo (saline) iv given as a single dose at anesthesia induction. Cognitive function was tested pre- and postoperatively by The Trail Making Test (TMT) A and TMT-B. Outcome of TMT is time (seconds) to complete the test; the longer the time, the worse the impairment. Primary endpoint was individual change preoperative to postoperative day (POD) 1 on TMT-B. Secondary endpoints were individual change preoperative to: POD1 on TMT-A, POD2 on TMT-A and TMT-B, and POD30 on TMT-A and TMT-B, respectively. ResultsA total of 33 patients (MP: n = 17; placebo: n = 16) were analyzed for primary endpoint. There was no significant difference between the groups in primary endpoint (MP group median 1s (IQR -7 − 23) vs. placebo group median 12s (IQR -5 − 34), p = 0.521). The MP group was significantly faster than the placebo group preoperative to POD30 on TMT-A (MP group median −10s (IQR -16 − 4) vs. placebo group median -4s (IQR -8 – 1), p = 0.046). There were no significant differences in remaining secondary endpoints. ConclusionPreoperative high-dose GC is not associated with increased risk of early POCD in elective AWR for a large incisional hernia.

Botulinum toxin A in abdominal wall reconstruction for incisional hernia: an interesting line of research in abdominal wall and plastic surgery

Botulinum toxin A in abdominal wall reconstruction for incisional hernia: an interesting line of research in abdominal wall and plastic surgery

AB078. SOH22ABS127. The ‘sandwich’ technique for large and complex incisional hernias: a retrospective review

Background: Repair of large incisional hernias is challenging as primary fascial closure often cannot be achieved. The peritoneal flap hernioplasty, or ‘sandwich’ incisional hernia repair (SIHR), serves to close the fascial gap by utilisation of the thickened hernia sac which also isolates the mesh from intraperitoneal contents and the subcutaneous space. We report outcomes from utilisation of this technique in our institution.

A transverse abdominis release and posterior component separation for large incisional hernia

Incisional hernias are a common complication of abdominal surgeries. About one third of all abdominal surgeries are prone to develop incisional hernias. An incisional hernia occurs at / or in close proximity to the surgical incision through which the contents of the abdomen may protrude. The incidence further increases in emergency procedures. This is one such case of a large incisional hernia in a patient who underwent emergency laparotomy for ileal perforation and presented with a large incisional hernia 3 months later. Transverse Abdominis Release with Posterior Component Separation was done and the patient was discharged on 11th postoperative day. Transverse abdominis release is a durable and reliable surgical repair for large incisional hernias.

BMI: does it predict the need for component separation?

Patient optimization and selecting the proper technique to repair large incisional hernias is a multifaceted challenge. Body mass index (BMI) is a modifiable variable that may infer higher intra-abdominal pressures and, thus, predict the need for component separation (CS) at the time of surgery, but no data exist to support this. This paper assesses if the ratio of anterior-posterior (AP): transverse (TRSV) abdominal diameter, from pre-operative CT imaging, indicates a larger proportion of intra-abdominal fat and correlates with a hernia defect requiring a component separation for successful tension-free closure. Ninety patients were identified who underwent either an open hernia repair with mesh by primary closure (N = 53) or who required a component separation at the time of surgery (N = 37). Pre-operative CT images were used tomeasure hernia defect width, AP abdominal diameter, and TRSV abdominal diameter. Quantitative data, nominal data, and logistic regression was used to determine predictors associated with surgical group categorization. The average hernia defect widths for primary closure and CS were 7.7 ± 3.6cm (mean ± SD) and 9.8 ± 4.5, respectively (p = 0.015). The average BMI for primary closure was 33.9 ± 7.2 and 33.8 ± 4.9 for those requiring CS (p = 0.924). The AP:TRSV diameter ratios for primary closure and CS were 0.41 ± 0.08 and 0.49 ± 0.10, respectively (p < 0.001). In a multivariate analysis including both defect width and AP:TRSV diameter ratio, only AP:TRSV diameter ratio predicted the need for a CS (p = 0.001) while BMI did not (p = 0.92). Intraabdominal fat distribution measured by AP:TRSV abdominal diameter ratio correlates with successful tension-free fascial closure during incisional hernia repair, while BMI does not.