Preoperative Progressive Pneumoperitoneum Research Articles

INTRAOPERATIVE FASCIAL TRACTION FOR TREATMENT OF W2 AND W3 VENTRAL HERNIAS

Abstract Background Component separation techniques are increasingly employed in abdominal wall reconstruction surgery. The use of adjuvant techniques, such as intraoperative vertical dynamic fascial traction, enhances the compliance of the abdominal wall. This facilitates closure of the abdominal wall using less disruptive techniques without compromising effective treatment. Our aim is to retrospective review our results regarding the effectiveness and complication rate of intraoperative fascial traction for the treatment of complex ventral hernias. Method Conducted a retrospective analysis of 10 patients who underwent surgery using intraoperative fascial traction for W2 and W3 ventral hernias. Results Preoperatively, fascial distances measured ranged from 55 cm to 145 cm, with the majority of patients (70%) having a fascial distance greater than 10 cm. Most patients received other adjuvant treatments (nine cases with botulinum toxin injection and one with pre-operative progressive pneumoperitoneum). Posterior component techniques were employed in 40% of patients (half with W2 hernias and the other half with W3 hernias). The complication rate was 10%, with one case of hemorrhage requiring percutaneous embolization. During the average 6-month follow-up period (ranging from 1 to 17 months), one recurrence was observed. Conclusion Intraoperative fascial traction is a feasible and safe adjuvant technique for abdominal wall reconstruction. The use of adjuvants in complex abdominal wall hernia surgery may, in some patients, downstage the hernia, thereby avoiding the need for component separation techniques. This approach enables tension-free closure of the abdominal wall in a less invasive manner.

Iatrogenic massive pneumothorax after preoperative progressive pneumoperitoneum

Iatrogenic massive pneumothorax after preoperative progressive pneumoperitoneum

Anterior versus posterior component separation technique for advanced abdominal wall reconstruction: a proposed algorithm.

The precise indications for employing the anterior component separation technique (ACST) and the Transversus Abdominis Release (TAR) in abdominal wall reconstruction (AWR) remain uncertain, despite the undeniable value of both techniques. The aim of this study was to analyze the anterior fascial closure rate, postoperative wound morbidity, and hernia recurrence rate for both procedures according to the algorithm used for complex AWR. A retrospective analysis of prospectively collected data was carried out. Patients undergoing AWR for midline incisional hernias using either open or endoscopic ACST (E-ACST) or TAR between March 2013 and August 2022 were included. Patients with lateral hernia components were excluded. The surgical technique was depending on the pre- and intraoperative findings regarding hernia width and on the estimated traction to achieve anterior fascial closure (see algorithm). Initially, intermediate hernia defects ranging from approximately 10-14cm in width were repaired using E-ACST. However, as the study advanced, TAR became the preferred method for addressing these types of defects. Open ACST was consistently employed for defects wider than 14-15cm throughout the entire study duration. Outcomes of interest were anterior fascial closure, surgical site occurrences, and hernia recurrence rate. Follow-up was performed at 1month, 1year, and 2years. A total of 119 patients underwent AWR with CST: 63 patients (52.9%) were included in the ACST group and 56 patients (47.1%) in the TAR group. No significant differences were observed in patient and hernia characteristics. The use of botulinum toxin A (BTA) injection and preoperative progressive pneumoperitoneum (PPP) was more frequently used in the ACST group (BTA 19.0%, PPP 15.9% versus BTA 5.4%, PPP 1.8% for TAR patients). Anterior fascial closure was achieved in 95.2% of the ACST group and 98.2% of the TAR group (p = 0.369). The TAR group demonstrated a significantly lower SSO rate at one month (44.3% versus 14.3%, p < 0.001) and required fewer procedural interventions (SSO-PI) (31.1% versus 8.9%, p = 0.003). The recurrence rate at one year was low and there was no statistically significant difference between the two groups (ACST 1.8% vs TAR 4.5%, p = 0.422). Following a proposed algorithm, the anterior fascial closure rate was high and similar for both techniques. As postoperative wound morbidity is significantly increased after ACST, our findings support recommending TAR for defects up to 14cm in width, while favoring open ACST for larger defects.

Botulinum Toxin A as an Adjunct for the Repair Giant Inguinal Hernias: Case Reports and a Review of the Literature.

The management of giant inguinoscrotal hernias remains a challenge as a result of the loss of the intra-abdominal domain from long-standing hernia contents within the scrotum. Multiple techniques have been described for abdominal wall relaxation and augmentation to allow the safe return of viscera from the scrotum to the intraperitoneal cavity without adversely affecting cardiorespiratory physiology. Preoperative progressive pneumoperitoneum, phrenectomy, and component separation are but a few common techniques previously described as adjuncts to the management of these massively large hernias. However, these strategies require an additional invasive stage, and reproducibility remains challenging. Botulinum toxin A (BTA) has been successfully used for the management of complex ventral hernias. Its use for these hernias has shown reproducibility and a low side effect profile. In the present report, we describe our institutional experience with BTA for giant inguinal hernias in two patients and present a review of the literature. In one case, a 77-year-old man with a substantial cardiac history presented with a giant left inguinal hernia that was interfering with his activities of daily living. He had BTA six weeks prior to inguinal hernia repair. Repair was performed via an inguinal incision with a favorable return of the viscera into the peritoneum. He was discharged on the same day of the operation. A second patient, 78 years of age, had a giant right inguinoscrotal hernia. He had a significant cardiac history and was treated with BTA six weeks prior to inguinal hernia repair via a groin incision. Neither patient had complaints nor recurrence at 7- and 3-month follow-ups. While the literature on this topic is scarce, we found 13 cases of inguinal hernias treated with BTA as an adjunct. BTA might be a promising adjunct for the management of giant inguinoscrotal hernias in addition to or in place of current strategies.

Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic Review.

Introduction: Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTX) have been used together in the preoperative preparation of patients with loss of domain hernias. This study aims to evaluate the efficacy and safety of the combined use of PPP and BTX. Methods: A systematic electronic search was performed according to the PRISMA criteria. A literature search of scientific articles was conducted up to December 2023. Articles were chosen based on the reference to BTX and PPP in loss of domain ventral hernias with a defect width greater than 10cm before surgery. The GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. Results: The research yielded seven articles, with 217 patients analysed in total. BTX was performed 29.5 ± 1.7 days before surgery and PPP was inflated 14.8 ± 5.8 days before surgery. PPP complications were reported in 25.6% of patients, The average reduction of the volume of hernia (VH)/volume of the abdominal cavity (VAC) ratio was 7.6% (range 0.9%-15%). Only 40 patients (18.4%) required a PCS or TAR to repair the loss of domain hernias. The SSI and SSO rates were 17.5% and 26.2%, respectively. No differences in SSI and SSO rates were found between the different repair techniques. The recurrence rate was 5.9% (13/217). Recurrence was significantly higher in patients who underwent IPOM repair than other techniques (p < 0.001). Conclusion: BTX and PPP may be useful tools for the management of loss of domain hernias presenting lower SSI and SSO. The combination of BTX and PPP reduces the use of more invasive repair techniques.

Progressive preoperative pneumoperitoneum in a patient with giant inguinal hernia: report of a case

Giant hernias have chronic abdominal wall defects that slowly and progressively grow and alter the normal physiology of the abdominal wall. The clinical case we report is a 76-year-old male who began 7 years ago with protrusion in the left inguinal area with progressive increase in volume until reaching the inability to walk is presented. The protocol is followed by pneumoperitoneum insufflation with 500-1000 milliliters (ml) of carbon dioxide daily for 10 days. The treatment of large hernia defects of the abdominal wall produces a large increase in intra-abdominal pressure during visceral reduction, which entails an alteration in cardiorespiratory biomechanics by elevating the diaphragm and reducing venous return. This technique would be indicated in hernias greater than 10 centimeters (cm), as well as in large inguinal and umbilical hernias, with irreducible sacs, with "loss of domain". It is protocolized with preoperative preparation with pneumoperitoneum for 10 days, for subsequent inguinal plasty with Lichtenstein technique, during which a minimum of adhesions were found, managing to preserve the ipsilateral testicle, reducing surgical time and hospital stay, with no data on compartment syndrome in the abdomen after surgery, providing a good alternative in this type of condition.

Preoperative Abdominal Muscle Elongation Facilitated Laparoscopic Intraperitoneal Onlay Mesh Repair of Complex Ventral Hernia.

Background: Complex ventral hernia remains a challenging situation for any surgeon. In this study, our aim was to analyze the effect of laparoscopic intraperitoneal onlay mesh (IPOM) repair in the treatment of complex abdominal wall hernia, with the assistance of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA). Methods: In this retrospective study, we included 13 patients with complex ventral hernia between May 2021 and December 2022. All patients undergoing PPP and BTA protocol before hernia repair. The length of abdominal wall muscles and abdominal circumference were measured from CT scan. All hernias were repaired with laparoscopic or laparoscopic-assisted IPOM. Results: Thirteen patients received PPP and BTA injections. PPP and BTA administration time was over 8.8 ± 2.5 days. Before and after PPP and BTA, imaging showed that the length of lateral muscle on each side increased from 14.3 to 17.4 cm (P < .05). The abdominal circumference increased from 81.8 to 87.9 cm (P < .05). Complete fascial closure was obtained in 13 patients (100%), and no patient experienced postoperative abdominal hypertension and ventilatory support. No patient suffered from recurrent hernia to date. Conclusions: Preoperative PPP combined with BTA injection plays a role similar to component separation technique, avoids the abdominal hypertension after laparoscopic IPOM repair of complex ventral hernia.

Re-discussion on the comprehensive treatment strategy of complex ventral hernia from the perspective of intraperitoneal pressure

Complex ventral hernia refers to a large hernia that is complicated by a series of concurrent conditions. Change in intra-abdominal pressure is one of the main pathways through which various factors exert an impact on perioperative risk and postoperative recurrence. Taking abdominal pressure reconstruction as the core, the treatment strategy for complex abdominal hernia can be formulated from three aspects: improving patients' tolerance, expanding abdominal cavity volume, and reducing the volume of abdominal contents. Improving patients' tolerance includes abdominal wall compliance training and progressive preoperative pneumoperitoneum. To expand the volume of the abdominal cavity, implanting hernia repair materials, component separation technique, autologous tissue transplantation, component expend technique, and chemical component separation can be used. Initiative content reduction surgery and temporary abdominal closure may be performed to reduce the volume of abdominal contents. For different cases of complex ventral hernia, personalized treatment measures can be safely and feasibly adopted depending on the condition of the patients and the intra-abdominal pressure situation.

P-067 PREHABILITATION IN A LOSS OF DOMAIN BILATERAL INGUINOSCROTAL HERNIA: USE OF BOTULINUM TOXIN AND PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM

Abstract Aim Describe the use of botulinum toxin A (BT) and preoperative progressive pneumoperitoneum (PPP) in a loss of domain inguinoscrotal hernia following our hospital's protocol. Material and methods Single case report of a 60-year-old male, with loss of domain bilateral inguinoscrotal hernia. We performed prehabilitation with respiratory physiotherapy (RP), BT and PPP. We applied BT 30 days before surgery, injecting a total of 500U in 12 sites of abdominal wall: 4 in the lateral abdominal muscle and 2 of them in each rectus abdominis. We calculated, using the Tanaka index, the ratio between the abdominal cavity volume (ACV) and the hernia volume (HV), which was 32%, as well as the amount of pneumoperitoneum to insufflate, which according to our protocol is HV x3 + 100cc. The PPP catheter was placed 10 days before repair, insufflating a total of 6.900cc within seven consecutive days of catheter placement. Results With the application of prehabilitation (BT, RP, PPP) we achieve a lengthening of 18.5 cm and a decrease of 27 mm of the thickness as well as an increase in the volume of the abdominal cavity of×4.200cc. Afterwards, a hernioplasty with Stoppa and bilateral Litchenstein technique was performed. as well as a scrotoplasty and circumcision for the patient's phimosis in collaboration with Plastic and Urology services. The surgical procedure was performed without complications. After 7 months there is no hernia recurrence. Conclusions BT and PPP help to repair the inguinoscrotal hernia, avoiding the mayor surgical techniques like component separation diminishing morbidity.

P-006 OUR EXPERIENCE WITH TAR FOR COMPLEX INCISIONAL HERNIA REPAIR

Abstract Aim Transverse abdominis muscle release (TAR) enables dissection of the preperitoneal space and the placement of large meshes. We present our experience with TAR in the treatment of complex incisional hernias (IH). Material and Methods Retrospective, descriptive study of patients operated with the TAR technique (October 2019-July 2022). Epidemiological characteristics, comorbidity, prehabilitation, type of IH, bridging, surgical time, hospital stay, morbidity, mortality and recurrence were studied. Results 69 TAR (30 females/39 males); age 64.9 years (24–85), body mass index 31 (19–49), CeDAR 35% (4–92). 66 cases (96%) treated preoperatively with Botulinum Toxin A, 31 (45%), with preoperative progressive pneumoperitoneum and 29 (42%) with both. Classification (EHS): M 52 (46%), L 7 (10%), ML 9 (13%), parastomal 1 (1%), tumour 1 (1%). 36 cases R0 (52%), R1 22 (32%), R2 4 (10%) and R3 6 (9%). Median size 17.8 cm(3–30) x13.7 cm (6–25), area 694.3 cm2. Primary fascial closure was achieved in 26 cases (38%), remaining 43 (62%) with bridging (8.7 cm (2–19)x5 cm (1–16)), postoperative area 125.6 cm2 (82% reduction). Surgical time was 242 minutes (140–450). Hospital stay 9 days (3–45). Wound-related complications 35 (50%): infection 15 (21%), seroma 17 (24%), haematoma 15 (7%), skin necrosis 1 (1%). General complications 7 (10%): 2 urinary tract infection, 1 intestinal perforation, 1 pneumonia, 1 haematoma, 1 haemorrhagic shock, 1 heart failure. Mortality 2 (3%). Recurrences 0 (0%). Conclusions TAR is a very useful and effective technique for resolving complex eventrations. It is not exempt from morbidity, therefore adequate patient selection is recommended.

P-049 DAMAGE CONTROL SURGERY FOR AN INCARCERATED GIANT UMBILICAL HERNIA IN A SUPEROBESE PATIENT

Abstract Aim To report the case of the emergency management of an incarcerated giant umbilical hernia in a superobese patient with a damage control surgery as the first step for its treatment. Material &amp; Methods We present the case of a 47-year-old man with a BMI of 62 kg/m2 who arrived to the emergency department for abdominal pain. Examination and CT scan revealed a giant umbilical incarcerated hernia with loss of domain, with an 8 cm hernia neck and containing the entire bowel except for the rectosigmoid and duodenum. Results The emergency managment was a laparotomy with a subcutaneous right lateral approach, opening first the hernia sac to verify bowel viability. Then, we performed a tranverse chelotomy on the right side of the defect, leaving the defect open and wider to prevent hernia strangulation. We left two drains in the subcutaneuos space and the wound was covered with vacuum therapy dressing. The patient recovery was uneventful and he was discharged in the sixth postoperative day. After this episode the patient started a very strict weight loss treatment, so we coul plan the final wall reconstruction surgery, which hasn't already been performed, but which will include botulinum toxin and progressive preoperative pneumoperitoneum. Conclusions We belive that damage control surgery was the most appropiate option as the first step for the management of an incarcerated complex hernia, so in a second time an elective complex wall reconstruction surgery could be performed.

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

Preoperative Progressive Pneumoperitoneum in the Treatment of Hernias With Loss of Domain. Our Experience in 50 Cases.

Introduction: Surgical planning for repair of giant hernias with loss of domain needs to consider patient comorbidities, potential risks and possible postoperative complications. Some postoperative complications are related to the increase in intra-abdominal pressure caused by the reintroduction of abdominal contents into the peritoneal space. Preoperative progressive pneumoperitoneum (PPP) increases the capacity of abdominal cavity prior to hernia repair and allows for better physiological postoperative adaptation. The aim of this study is to analyze perioperative and intraoperative characteristics as well as outcomes of a cohort of patients treated with PPP prior to giant hernia repair at a single, high volume center. Methods: Prospective, descriptive, observational single-center study including 50 patients undergoing PPP prior to hernia with loss of domain repair between January 2005 and June 2022. We analysed epidemiological, surgical and safety variables. Results: Fifty patients were included: 43 incisional hernias, 6 inguinal hernias and 1 umbilical hernia. Mean age was 66years (36-85). Median insufflation time was 12days (4-20) and median insufflated volume of ambient air was 10,036 cc. There were complications during PPP in nine patients: 2 decompensation of chronic respiratory disease and 7 subcutaneous emphysema. PPP was prematurely suspended in patients with respiratory decompensation. All patients with incisional and umbilical hernias underwent open repair with mesh placement. Preperitoneal repair was performed in inguinal hernias. Three cases of hernia recurrence were reported during the follow up. Conclusion: PPP is a safe and effective tool in the preoperative management of patients with giant hernias. It helps to achieve the decrease or absence of abdominal wall tension and can favour the results of complex eventroplasty techniques.

The outcomes of open anterior component separation versus posterior component separation with transversus abdominis release for complex incisional hernias: a systematic review and meta-analysis.

The main objective was to assess the prevalence of hernia recurrence, wound complications (surgical site infections [SSI], seroma and hematoma) and mortality after anterior component separation (ACS) and posterior component separation via transversus abdominis muscle release (PCSTAR) in patients with complex incisional hernias. The so-called complex IH is a serious medical and societal challenge due to its direct and indirect costs; it is also hampered by the use of different surgical techniques, different type of meshes, and different results heterogeneously reported and interpreted. According to actual data, the best approach seems to be a mesh reinforcement component separation procedure augmented or not with an adjuvant technique (preoperative progressive pneumoperitoneum and/or Botulin toxin type A infiltration). A systematic search of four databases (MEDLINE, PubMed, Web of Science, and Google Scholars) was conducted to identify studies reporting on outcomes of component separation techniques and which were published before December 2021. A systematic review and a meta-analysis of postoperative outcomes were performed. Nineteen studies including 3412 patients (1709 with ACS and 1703 with PCSTAR) were selected. Pooled hernia recurrence rate after a minimum 1-year follow-up was evaluated at 5.15% (odds ratio [OR] 0.68; 95% confidence interval [CI] 0.5-0.9; p = 0.0175). Pooled surgical site infection rate was 10.6% (OR 1.32; 95% CI 1.06-1.65; p = 0.0119). Seroma and hematoma were estimated at 9.75% (OR 1.93; 95% CI 1.52-2.44; p = 0.0001) and 3.83% (OR 1.81; 95% CI 1.26-2.61; p = 0.0012), respectively. ACS was associated with increased wound morbidity, seroma and hematoma. PCSTAR displayed higher recurrence rate (4.27% vs 6.11%). PCSTAR was superior to ACS in terms of wound morbidity, surgical site infections, seroma and hematoma incidence. The procedure should be further evaluated in comparative head-to-head randomized controlled trials.

Role of progressive preoperative pneumoperitoneum in the management of giant inguinoscrotal hernia-case report

Managing a giant inguinal hernia/ incisional/ ventral hernia had its own complications. The overtime adaptation of peritoneal cavity to a lower abdominal pressure was one of the most important factors responsible for these complications. Surgical repair is also quite a challenge because of the massive contents in sac, adhesions and concomitant fibrosis. In order to reduce the complications like intra-abdominal hypertension, cardiorespiratory problems and to increase the abdominal wall compliance, many techniques were described. Progressive preoperative pneumoperitoneum is a well described technique for the repair of giant inguinal hernia/ incisional/ ventral hernia with loss of domain which helps in conditioning the abdominal wall in the preoperative period, increasing the likelihood of primary closure and decreasing the incidence of compartment syndrome.

State-of-the-art abdominal wall reconstruction and closure.

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

OC-072 SYSTEMATIC REVIEW AND META-ANALYSIS OF PREOPERATIVE ADMINISTRATION OF BOTULINUM TOXIN AS ADJUNCT TO VENTRAL HERNIA REPAIRS

Abstract Aim Preoperative application of botulinum toxin (BTX), with or without preoperative progressive pneumoperitoneum (PPP), is an adjunct to complex ventral hernia repairs, causing flaccid paralysis. We aim to evaluate the benefit of BTX in the advancement of the lateral musculature and decrease hernia defect width. Material &amp; Methods It was elaborated a systematic review and meta-analysis following PRISMA guidelines and registered at PROSPERO. “Ventral hernia”, “incisional hernia”, “abdominal wall” and “botulinum toxin” were searched. PubMed (Medline), EMBASE (OVID) and LILACS databases research. Results Five studies (235 patients) showed tha BTX significantly increases the lateral abdominal wall muscles length (4,07cm) (95%CI (3.65;4.49), p&amp;lt;0,1 I2=47%). Two studies (113 patients) showes that hernia defect width raised 1.24 cm (95%CI (-3.06;5.53), p&amp;lt;0,05, I2=76%) after BTX with or without PPP. Conclusions Increase in the volume of the abdominal cavity after BTX and PPP by enlargement of abdominal wall muscles may be related to improve outcomes such as decreasing abdominal compartiment syndrome and surgical site occurrences. Despite the Increase in the lateral abdominal wall after BTX, the decrease in hernia defect width was not obseved. Insted, meta-analysis showed a tendency of width increasing, taking into account considerable heterogeneity, witch may be related to PPP association. BTX in complex ventral hernias increases lateral abdominal muscles length and, thus, is suposed to decrease poor surgical outcomes, although the transverse diameter of the defect does not reduced as expected. Futher studies are necessary to evaluate benefits of BTX in complete fascial closure.

P-024 COMPLEX ABDOMINAL WALL RECONSTRUCTION BY RETROMUSCULAR SUBLAY TECHNIQUE: INITIAL EXPERIENCE IN A THIRD-LEVEL HOSPITAL

Abstract Aim Large or complex incisional hernias require more than just mesh placement.There are techniques such as component separation, retromuscular techniques (Rives-Stoppa, transversus abdominis muscle release-TAR), which help to repair the hernia and physiologically rebuild the abdominal wall.However, this type of technique can present a higher incidence rate of complications, such as hematomas, seromas, SSI, skin necrosis.We present our initial experience in complex abdominal wall reconstruction using the retromuscular sublay technique (RST). Methods Retrospective study analyzing our database of patients with complex incisional hernia undergoing abdominal wall surgery using the RST, during November-2018 to October-2020.In addition, we conducted a comparative analysis with patients undergoing hernia repair using the onlay-technique. Results 44 patients underwent RST (male:56.8%, age:66(IQR: 52–73years)). Hospital stay:4(IQR: 2–6days).Pathological history: diabetes mellitus (4.5%), arterial hypertension(20.5%), dyslipidemia(36.4%), smoking(34.1%), alcohol consumption(27.3%), cardiovascular disease(9.1%).ASA-classification:I(9.1%), II(59.1%), III(31.8%). BMI: 29.3±2kg/m2. Hernia location: midline(95.5%), others(4.5%). Preoperative botulinum toxin (PBT): 20.45%. Preoperative progressive pneumoperitoneum (PPP): 9.1%. Type of surgery performed: Rives-Stoppa(68.2%), TAR(31.8%). Postoperative complications: global(13.6%), Clavien-Dindo≥III:0%, clinical seroma(13.6%) and ultrasound-seroma(22.7%), SSI(0%). Hernia recurrence:0%. In the bivariate analysis of patients undergoing hernia repair using the RST compared to patients undergoing onlay repair, we observed that the RST presented lower incidence of global complications, both clinical and ultrasound seromas, surgical site infections and recurrences (13.6% vs 39.1% p=0.004; 13.6% vs 33.3% p=0.019; 22.7% vs 39.1% p=0.07; 0% vs 14.5% p=0.008; 0% vs 5.8% p=0.1; respectively). Conclusions In our enviroment, the management of complex incisional hernias using RST and the use of PBT and PPP is effective and safe, with a lower incidence of complications and recurrences.

V-002 MASSIVE INGUINAL HERNIA REPAIR WITH CHEMICAL COMPONENT RELAXATION AND PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM

Abstract Inguinal hernias are one of the most common procedures performed worldwide. Conversely, massive or giant inguinal hernias; defined as extending below the midpoint of the inner thigh are very uncommon. They are often associated with loss of domain, posing a different set of challenges for the surgeon, specially creating intra-abdominal space for the displaced organs. Preoperative progressive pneumoperitoneum (PPP) coupled with chemical denervation with botulinum toxin A (BTA) is one way to increase the size of the intrabdominal cavity to aid in reduction of the hernia contents and closure of the defect. We present a case of a 51-year-old male with a massive right inguinal hernia with complete loss of domain. The hernia sac contained the entirety of his small bowel and colon except for his proximal duodenum and distal rectum which remained intrabdominal. We preformed preoperative BTA chemical denervation and progressive pneumoperitoneum prior to staged open Inguinal hernia repair. 1 month preoperatively BTA injections were performed under ultrasound guidance into the external and internal obliques at 3 locations bilaterally and an intraabdominal catheter was placed under laparoscopic guidance. The patient was insufflated with filter air 3 times a week for 3 weeks. He then underwent open repair with preperitoneal mesh placed and orchiectomy.

P-025 USE OF PREOPERATORY PNEUMOPERITONEUM FOR GIANT INGUINOESCROTAL HERNIA TREATMENT WITH LOSS OF DOMAIN. A GREAT RESOURSE

Abstract Introduction Recently, the use of neoadjuvant therapies such as preoperative progressive pneumoperitoneum has favored the treatment of large ventral hernias with loss of domain. Despite this, there are only few cases described in the literature. Materials &amp; Methods We present a case of a 69-year-old male affected by giant inguinoescrotal hernia of years of evolution with loss of domain. A preoperative CT scan with volumetric quantification is performed where giant left inguinal hernia with mesenteric fat content, small intestine, sigma, descending colon, as well as splenic angle of the colon, with a relationship between the volumes greater than 0.67. (VSH of 11,502cc and VABD of 17,061cc). We decided to perform preoperative progressive pneumoperitoneum. In the following 15 days up to 8L are administered without complications. Results Surgical repair of the inguinal hernia is performed according to the Lichtenstein technique modified by the size of the hernial sac with evidence of unstructured but intact structures of the inguinal canal. Placement of self-adhesive ProGrip TM retroaponeurotic mesh is performed with attachment of this to the inguinal ligament and pubis. After surgery, the patient presented a good postoperative recovery without complications, without evidence of recurrence more than 6 months after surgery. Discussion The use of prehabilitating techniques in patients affected by large hernias can reduce the morbidity and mortality of patients, with the less aggression. In our case it allowed us to completely reduce all the hernia contents without visceral injury and perform an anatomical repair, which would not have been possible without this resource.