Hernia Repair Research Articles

Robotic minimally invasive inguinal hernia repair with the Dexter robotic system™: A prospective multicenter clinical investigation

Abstract Background Robot-assisted transabdominal preperitoneal inguinal hernia repair (rTAPP) has been established with various robotic platforms. The Dexter robotic system is an open platform consisting of a sterile surgeon’s console, two robotic instrument arms, and one robotic endoscope arm. This study aimed to confirm the perioperative and early postoperative safety and clinical performance of the Dexter system in patients undergoing primary transperitoneal inguinal hernia repair. Methods The primary objectives of this multicenter study conducted at three centers in France, Germany, and Switzerland were to document the successful completion of rTAPP procedures and the occurrence of serious adverse events (Clavien–Dindo grades III–V), device-related events up to 30 days post-surgery. The procedures were performed by three surgeons with varying levels of experience in robotic systems. Results 50 patients with a median age of 62.5 years (IQR 51.0–72.0) and BMI of 25.1 kg/cm2 (IQR 23.5–28.7), respectively, underwent inguinal hernia repair (33 unilateral, 17 bilateral). All surgeries were successfully completed using three standard laparoscopy trocars. There were no conversions to open surgery, intraoperative complications or device deficiencies. The median skin-to-skin operative time was 50 min (IQR 45–60) for unilateral hernias and 96 min (IQR 84–105) for bilateral hernias. The median console time was 30 min (IQR 26–41) for unilateral and 66 min (IQR 60–77) for bilateral hernias. Twenty-six patients were discharged on the day of surgery, and 22 on postoperative day 1. Conclusion This study confirmed the use of the Dexter system in rTAPP was feasible and safe in multicenter cohorts, with operative times consistent with the literature on other robotic platforms. Our data demonstrated the accessibility of this new robotic approach, even when adopted by surgeons new to robotics. The Dexter system emerged as a valuable device in the hernia repair toolkit for both experienced robotic surgeons and those new to the field.

Long-Term Outcomes of Component Separation for Abdominal Wall Hernia Repair

ImportanceComponent separation is a reconstructive technique used to facilitate midline closure of large or complex ventral hernias. Despite a contemporary surge in popularity, the incidence and long-term outcomes after component separation remain unknown.ObjectiveTo evaluate the incidence and long-term outcomes of component separation for abdominal wall hernia repair.Design, Setting, and ParticipantsThis cohort study examined 100% Medicare administrative claims data from January 1, 2007, to December 31, 2021. Participants were adults (aged ≥18 years) who underwent elective inpatient ventral hernia repair. Data were analyzed from January through June 2024.ExposureUse of component separation technique during ventral hernia repair.Main Outcomes and MeasuresThe primary outcomes were the incidence of component separation over time and operative recurrence rates up to 10 years after surgery for hernia repairs with and without component separation. The secondary outcome was rate of operative recurrence after component separation stratified by surgeon volume.ResultsAmong 218 518 patients who underwent ventral hernia repair, the mean (SD) age of the cohort was 69.1 (10.9) years; 127 857 patients (58.5%) were female and 90 661 (41.5%) male. A total of 23 768 individuals had component separation for their abdominal wall hernia repair. The median (IQR) follow-up time after the index hernia surgery was 7.2 (2.7-10) years. Compared with patients who did not have a component separation, patients undergoing repair with component separation were slightly younger; more likely to be male; and more likely to have comorbidities, including obesity, and had surgeries that were more likely to be performed open and use mesh. Proportional use of component separation increased from 1.6% of all inpatient hernia repairs in 2007 (279 patients) to 21.4% in 2021 (1569 patients). The 10-year adjusted operative recurrence rate after component separation was lower (11.2%; 95% CI, 11.0%-11.3%) when compared with hernia repairs performed without component separation (12.9%; 95% CI, 12.8%-13.0%; P = .003). Operative recurrence was lower for the top 5% of surgeons by component separation volume (11.9%; 95% CI, 11.8%-12.1%) as opposed to the bottom 95% of surgeons by volume (13.6%; 95% CI, 13.4%-13.7%; P = .004).Conclusions and RelevanceThis study found that component separation was associated with a protective effect on long-term operative recurrence after ventral hernia repair among Medicare beneficiaries, which is somewhat unexpected given the intent of its use for higher complexity hernias. Surgeon volume, while significant, had only a minor influence on operative recurrence rates.

AHP SO03 - The role of the specialist upper gastrointestinal (UGI) benign dietitian in the management of benign UGI disorders – a review of the outpatient referral base

Abstract Background Benign UGI disorders can negatively affect patients’ nutritional status by impacting on oral intake and/or through malabsorption. GSTT performs a high volume of benign UGI surgeries and is a tertiary referral centre for oesophageal reconstructions and complex hernias. The role of the dedicated specialist UGI benign dietitian was established in 2019 to provide dietetic expertise to the UGI multidisciplinary team (MDT). It supports patients before and after surgery with the aim of reducing post-operative complications, length of hospital stay, re-admissions and improving patient experience and quality of life. Method Outpatient referrals to the UGI benign dietetic service between 02/02/2024 and 06/06/2024 were reviewed for source of referral, reason for dietetic referral and UGI diagnosis. Results Twenty-five new referrals were received from a variety of clinical specialities (table 1). The primary UGI disorders of referrals are outlined in table 2, with complex hernia repair being the most common. Table 3 outlines the broad range referral reasons. Nutrition support referrals were received for the following disorders: achalasia, oesophageal stricture and following oesophageal perforation, hiatus hernia repair, cholecystectomy and oesophagectomy. All weight management referrals were for complex hernia repair patients. Referrals for the side-effects of UGI surgery included dietetic support with pancreatic exocrine insufficiency (pancreatectomy; distal gastrectomy), dumping syndrome (hiatus hernia repair) and delayed gastric emptying (oesophagectomy). Conclusion The role of the benign UGI dietitian requires skills and expertise in a broad range of dietetic interventions. The service is well utilised by surgical and non-surgical colleagues. Next steps for service development would be to review the impact of interventions on surgical and patient reported outcomes, and explore feasibility of patient groups to deliver dietetic advice (for example weight reduction prior to surgery) to improve capacity within the service.

BN SO53 - Thoracotomy for the Repair of Giant Paraesophageal and Hiatal Hernias: A Systematic Review

Abstract Background The utilisation of transthoracic approaches for the repair of large hiatus hernias remains a topic of clinical debate. This study aims to evaluate and compare the efficacy, safety, and recovery metrics for transthoracic hiatal hernia repair and comparisons to the laparoscopic approach. Method A literature search was conducted using the key terms "hiatus hernia," "thoracotomy," "thoracic approach," and "Belsey Mark IV." The databases searched included MEDLINE, EMBASE, and Web of Science, covering the period from 2000 to June 2024. Extracted data included patient demographics, study design characteristics, length of stay, complication rate and mortality rate. Results A total of 5 citations were selected comprising a total of 560 patients of which 164 were male (29.3%) with an overall mean age was 64.9 (pooled SD = 1.93) and weighted mean follow-up length was 56.4 months (pooled SD = 39.1 months). The weighted overall mean length of stay was 14.5 days (Pooled SD = 7.42). The overall rate of minor complications was 19% (95% CI [6%, 31%]). The overall rate of major complications was 13% (95% CI [6%, 21%]). There were 4 reported mortalities in total and an overall leak rate of 1% (95% CI [0%, 2%]). Conclusion Both thoracotomy and laparoscopy have unique benefits and risks in the context of hiatal hernia surgery. Access via thoracotomy is associated with a higher incidence of complications. However, for large or emergent paraesophageal hernias, the transthoracic approach may represent a viable option in select patients.

BN SO62 - Laparoscopic technique for right sided paraduodenal hernia repair: A clinical study and surgical insights

Abstract Background Paraduodenal hernias can present significant diagnostic and therapeutic challenges, with up to 50% potentially leading to bowel obstruction. A minimally invasive approach to repairing these defects offers reduced morbidity and quicker recovery. This report highlights the feasibility and safety of laparoscopic repair of a right-sided paraduodenal hernia. Method A 19-year-old female presented with persistent postprandial bilious vomiting and a long history of forceful regurgitation 10-30 minutes after eating. The preoperative evaluation, surgical technique and operative outcomes are detailed. Results Preoperative evaluation included magnetic resonance imaging, computed tomography and a barium swallow, revealing an incidental finding of the duodenojejunal flexure and most jejunal loops on the right side of the abdomen. A right paraduodenal hernia was diagnosed during laparoscopy. After delineating and reducing the hernia laparoscopically, the sac was obliterated by opening up the posterior aspect over the inferior vena cava. The repair was completed by suturing the hernia orifice and plicating the duodenum. The patient's symptoms resolved postoperatively, with no intraoperative or immediate postoperative adverse outcomes reported. Scheduled outpatient follow-up showed satisfactory resolution of symptoms. Conclusion The laparoscopic repair of the right paraduodenal hernia was successfully performed, leading to the resolution of the patient's symptoms. This case underscores the importance of considering laparoscopic approaches for managing complex and rare hernias, especially when cross-sectional imaging modalities do not clearly identify the cause of symptoms. The laparoscopic technique offers significant advantages, including reduced pain and faster recovery.

BN SO36 - Robotic versus laparoscopic giant hiatus hernia repair - is one superior in clinical outcomes?

Abstract Background The number of robotic giant hiatal hernia repair (RGHHR) procedures is steadily increasing. RGHHR offers several potential advantages over traditional laparoscopy, including enhanced visualisation, superior ergonomics, and the use of articulating instruments, which can be particularly beneficial in the restrictive operating field of the diaphragmatic hiatus. However, the outcomes of RGHHR remain heterogeneous, both when reported alone and in comparison to laparoscopic giant hiatus hernia repair (LGHHR). This study aims to evaluate and compare the key clinical outcomes of RGHHR and LGHHR in adult patients. Method All patients undergoing primary giant hiatus hernia (GHH) surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service. Retrospective review of electronic records were utilised to document: patient demographics, hernia type, operative details. Use of mesh and gastropexy (as proxy measures to indicate difficulty of operation). Follow-up duration in weeks. Open cases within this cohort were excluded. Outcomes were: length of stay (LOS), 30-day morbidity measured using Clavien-Dindo (CD) grading, RTT and 30-day mortality. Analysis was undertaken using un-paired t-test and Chi2. A p-value of <0.05 was considered statistically significant. Results Table 1. Patients LGHHR RGHHR p n 56 29 Age (median) 71 (31-93) 66 (39-85) 0.1303 Female (%) 68.7 70 0.8988 BMI 31.8 (±6.4) 29.9 (±3.4) 0.1715 ASA grade (average) 2.4 2.2 0.0587 Hernia Types (median) 3 3 0.4411 Median follow-up (weeks) 8 (1-161) 12 (3-172) 0.5763 Table 2. Operative details LGHHR RGHHR p Mesh used (%) 9.1 0 0.0907 Gastropexy (%) 12.7 6.9 0.4175 Table 3. Outcomes LGHHR RGHHR p LOS (median) 1 (0-161) 2 (0-15) 0.4177 30-day morbidity (CD≥3, %) 3.6 6.9 0.9193 RTT (%) 9.1 6.9 0.5570 30-day mortality 0 0 NA Conclusion RGHHR approach has been successful in managing complex GHH, with low RTT, low co-morbidity and no mortality. In our institution RGHHR has demonstrated non-inferiority to LGHHR in respect to clinical outcomes. Patient factors and hernia types did not affect case selection. Use of mesh and gastropexy showed no difference in outcomes between the two groups. Cost, operative time and surgeon strain/fatigue were not evaluated in this study, however, these would provide useful additional comparative markers for the future.

BN SO45 - Reported criteria and safety for day case management of acute appendicitis

Abstract Background Acute appendicitis has an incidence of 7-8%. About 45,000 appendicectomies are performed in UK/year. Whilst day case surgery (DCS) is standard for cholecystectomies, hernia repair and even gastric bypass, reluctance exists in application of day care pathway for acute appendicitis. We aimed to review published literature on patient selection criteria, rates of day case discharge, readmission and re-intervention rates and patient satisfaction. Method A literature search was conducted in Embase, Pubmed and Medline for day case appendicectomy, Patient safety, selection criteria. A total of 116 papers were found. Once duplicates were removed, 75 studies underwent abstract screening from which 41 were full text screened. 29 publications were included in this review study. Data was collected on criteria for patient selection, length of stay, rate of DCS, rates of re-admission and re-intervention and patient/ relative satisfaction. Results Studies assessed DCS in children and/or adults. All authors included patients with uncomplicated appendicitis, well managed pain without opioid analgesia and adequate social support. Other authors additionally, only included patients under 65yrs old. The rates of DCS varied between 36.9% - 87%. Factors affecting DCS were time of admission and operation, female patients, symptom control and social factors. Rates of readmission ranged between 0-2.5% with no difference between DCS and admitted patients. Rates of re-intervention were low (0-2.5%) with a high patient satisfaction (87-91%). Late evening finishing of operation led to patient admission (77%) with no complications occurring within 48hrs. Conclusion Day case surgery for appendicectomy is reported to be safe provided adequate patient education and clear criteria for patient selection. No significant difference was found between the rates of re-intervention and re-admission between day case and admitted patients. We suggest standardising care pathways and provision of adequate education to both patients and staff as a method of safe day care discharge.

BN SO32 - Operative techniques and outcomes following giant hiatus hernia repair: 5 years of tertiary centre experience

Abstract Background Giant hiatus hernia (GHH) repair is a complex surgical challenge, often requiring advanced techniques and specialised expertise. Whilst the repair of small hiatus hernias is well-documented, the optimal strategy for giant hernias remains debated. This study reviews five years of experience at a tertiary centre, focusing on operative techniques and outcomes. The aim is to identify trends and best practices that enhance patient outcomes and minimise complications in the repair of GHH. Method All patients undergoing primary GHH surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service. Retrospective review of electronic records were utilised to document patient demographics, type of hernia, operative details including surgical approach (open/laparoscopic/robotic), use of fundoplication, use of mesh and gastropexy. Outcomes measured included 30-day morbidity (Clavien-Dindo (CD) grading), 30-day mortality, binary symptom recurrence, length of stay (LOS), need for return to theatre (RTT) and RTT versus mesh use. Analysis undertaken using paired t-test. Statistical significance was set as p<0.05. Results 91 patients underwent GHH repair with median age 70 (31-93) years, 66.7% female, average BMI 30.8(±5.4). ASA: ≤2 (72.4%), 3 (25.5%), 4 (2.1%). Hernia types: 2 (15.7%), 3 (55.4%), 4 (28.9%). Approach: open 6.6%, laparoscopic 61.5%, robotic 31.9%. Fundoplication in 88%, gastropexy in 13%, 2 cases utilised both. Mesh: 91.2% without, 8.8% biologic, nil prosthetic. Median LOS 2 days (0-161). Median follow-up 8 weeks (1-172). Symptoms recurred in 25.6%. 94.5% had no significant complications (CD≤2). 5.5% had RTT≤30 days. 4.4% RTT>30 days. No mortalities. No significant difference in RTT and mesh use (p=0.7832). Conclusion This five-year review confirms that GHH repair using open, laparoscopic, and robotic techniques is effective and safe, even in an older population with high ASA scores. The study highlights minimal complications (94.5% with CD≤2). Only 4.8% required a RTT within 30 days. RTT was not significantly impacted by the use of mesh however this may represent a type two error given the limited use of mesh and low number of patients that RTT. These findings support the tailored use of advanced surgical techniques, mesh, and gastropexy as effective strategies for managing GHH in a tertiary care setting.

BN SO42 - Our experience of Emergency Laparoscopic Fundoplication in a DGH

Abstract Background Emergency presentation of hiatal hernias can be life-threatening and is associated with high morbidity and mortality rates. Elective Laparoscopic hiatus and paraoesophageal hernias are commonly performed with fundoplication. However, emergency cases are often repaired without an anti-reflux procedure. We present our experience of emergency Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication in a District General Hospital (Russells Hall Hospital, RHH). Method 6 cases of diagnosed hiatus/ paraoesophageal hernia that underwent Emergency fundoplication from 2019-2024. Results The mean age of the patients was 74 (56-83). All patients had a pre-op CT scan to confirm the diagnosis. 4 patients (66%) had a Type 3 Hiatus hernia and 2 (33%) had a Type 2 classic paraosephageal hernia. All patients underwent Emergency Laparoscopic Hiatus / Para oesophagal hernia repair with fundoplication. 2 patients required mesh for the repair. The mean length of stay was 5 days (3-7). There were no intra or post-op complications and on follow up 1 patient had a recurrence of symptoms after 1 year requiring redo fundoplication. Conclusion The choice of operation is mainly based on the patient’s clinical condition, the complexity of the hernia and the surgeon’s experience. Our experience at RHH shows that Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication is safe and feasible in patients with emergency presentation.

MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia

Abstract Background Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population. The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia. Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility. Method Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic. She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome. This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA. Results Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy. Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying. Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery. Conclusion Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures. Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions. Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.

OGC SO38 - Laparoscopic repair of para-conduit hernia post minimally invasive esophagectomy using anterior hiatal suture repair and mobilisation of left liver lobe as reinforcement

Abstract Background Para-conduit hernia (PCH) formation is a rare and late complication of oesophagectomy that is associated with high risk morbidity. Minimally invasive oesophagectomy is associated with increased incidence of PCHs when compared to open or trans-hiatal oesophagectomies. Various techniques to repair PCHs including mesh repair, anterior/posterior hiatal suture repairs or even careful 360 degree repairs have been described in the literature1,2. But the risk of recurrence of PCH still remains high. We describe a unique laparoscopic technique which we believe to be associated with reduced risk of recurrence of PCH post-surgical repair. Method We present 4 cases of symptomatic PCH repairs performed laparoscopically. In this unique technique the contents of the sac is reduced and the hiatus is repaired anteriorly with interrupted ethibond sutures. The left lobe of the liver is mobilised and glued to the greater curve omentum along the conduit and the hiatus. This latter step is an additional way of preventing intraabdominal contents from entering the mediastinum. Data was collected retrospectively to include: patient demographics, details of original MIO surgery, pre-op imaging and details of the presenting symptoms with PCH including imaging, operative details and all available follow up. Results Between January 2022 and July 2024, 4 patients underwent laparoscopic repair of paraconduit hernia within 1-2 years post MIO. 3 were male and 1 female aged between 56-71 years. 3 of the procedures were performed electively and one as an emergency. All presented with symptomatic paraconduit hernias and managed with surgery using the technique described above. We present a video of laparoscopic repair as described. Conclusion We report a case series of 4 patients presenting with symptomatic PCH that were managed safely with a unique laparoscopic technique using suture repair and left liver lobe mobilisation to prevent recurrence of PCH.

BN SO48 - Antibiotic prescribing for elective inguinal hernia repairs

Abstract Background Inguinal hernia repairs are a common procedure with over one million operations performed annually in Europe and the US. The European Hernia Society do not recommend the routine use of antibiotics in low-risk patients due to no significant benefit. They advise the consideration of prophylaxis for patients with risk factors including recurrence, age > 70 years or immunosuppression. Many surgeons are using antibiotic prophylaxis in all patients. However, inappropriate antibiotic use contributes to increased antibiotic resistance and increased healthcare cost. Our trust guidelines recommend a single dose of Cefuroxime in all patients undergoing an inguinal hernia repair with mesh. Method The aim of the project was to determine the compliance with current trust guidelines regarding antibiotic use in elective inguinal hernia repair with mesh. We also aimed to report on antibiotic prescribing patterns. Patients undergoing an elective inguinal hernia repair with mesh over a six-month period were identified. Data was collected retrospectively from electronic patient records and included patient’s age, if they were classed as high risk (age over 70, recurrence of hernia, diabetic, steroid therapy), if antibiotics were prescribed, and if so, which antibiotics were utilised. Results Eighty-five patients were included in the final data analysis. The median age of patients included was 67 years of age, and 93% were male. 41 patients were identified as high risk, and most patients were ASA II. Our results reported that 48% of patients were prescribed prophylactic antibiotics at induction. However, only two patients were prescribed the correct antibiotic, as per trust guidelines. Most patients were prescribed Co-Amoxiclav (78%), with a range of other antibiotics being used, including Flucloxacillin, Clarithromycin and Metronidazole. We identified 37% of high-risk patients were not prescribed antibiotics. Conclusion Our trust guidelines were not reflective of best practice and did not consider individual patient or procedure risk factors. We identified varied antibiotic prescribing patterns with low compliance to trust guidelines. Utilising our findings, we have created new guidelines, which recommend that in low-risk patients, routine antibiotic prophylaxis is not required. However, in the presence of patient-related risk factors as mentioned above, then a single dose of Cefuroxime is recommended. The updated guidelines will ensure good antimicrobial stewardship and reduce unnecessary antibiotic prescriptions. In addition, they accurately reflect the current evidence base surrounding antibiotic prophylaxis.

EGS SO13 - Evaluation of Different Surgical Risk Prediction Models in Predicting Morbidity and Mortality in Giant Hiatus and Diaphragmatic Hernia Repairs

Abstract Background Emergency giant hiatus hernia and diaphragmatic hernia repairs are associated with high rates of mortality and morbidity; different studies reported variable outcomes. Accurate risk assessment empowers patients to provide informed consent and also serves as a valuable tool for identifying individuals who may require enhanced postoperative care, such as respiratory support and critical care admission. Various risk prediction tools have been developed to assist clinicians in making decisions to aid in stratifying the risk of surgical management. We aimed to assess the effectiveness of different risk prediction models in predicting mortality and morbidity in this patient cohort. Method Retrospective analysis performed on cases between May, 2010 and January, 2021 in a tertiary adult upper gastro-intestinal centre. The outcomes from the operations were assessed and compared with the predicted morbidity and mortality for different risk prediction models. Including the Surgical Outcome Risk Tool (SORT), the National Emergency Laparotomy Audit (NELA), parsimonious NELA and the American College of Surgeons National Surgical Quality Improvement Programme (ACS-NSQIP). The models were compared using the area under the curve (AUC). Morbidity models included Portsmouth Physiological and Operative Severity Score (P-POSSUM) and the ACS-NSQIP. Morbidity was evaluated by calculating the comprehensive complication index (CCI). Results A total of 108 patients met the criteria and were included in the analysis. Among these 50.9% were females. The median age was 69 (IQR 59-78). The 30-day mortality rate was 6.93% (7 patients), six patients died during the same admission, and one patient died during a re-admission. ACS-NQSIP had the highest predictive power for mortality (AUC = 0.6344), in comparison to NELA (AUC=0.5665), parsimonious NELA (AUC=0.4866) and SORT (AUC = 0.4342). Both ACS-NSQIP and P-POSSUM showed moderate correlation to CCI (rho = 0.489, p<0.001 and 0.446, p<0.001 respectively). Conclusion ACS-NSQIP is a better predictor of both mortality and morbidity in emergency giant hiatus and diaphragmatic hernia repairs when compared to NELA, parsimonious NELA, P-POSSUM and SORT. Interestingly, parsimonious NELA had a lower prediction rate when compared with the older NELA model. ACS-NSQIP may have a role in pre-assessment and consenting of emergency hiatus and diaphragmatic hernia repairs. Multi-centre prospective studies could be used to validate these findings.

Post Operative Outcome of Desarda Technique Versus Lichtenstein Mesh Hernioplasty for Inguinal Hernia Repair

Background: Current inguinal hernia operations are generally based on anatomical considerations. Failures of such operations to some extents are due to lack of consideration of physiological aspects. Many patients with inguinal hernia are cured because of current techniques of operation, though factors that are said to prevent hernia formation are not restored. Therefore, the surgical physiology of inguinal canal needs to be reconsidered. In the year 2001, Mohan P Desarda first described a physiological repair technique of inguinal hernia, which is practiced in many centers with significantly positive outcome. To evaluate the post-operative outcome of Desarda technique versus Lichtenstein mesh hernioplasty in inguinal hernia repair, this research has performed. Materials and methods: This Quasi experimental study was carried out in Surgery Department of Chittagong Medical College Hospital, during December 2017 to January 2019. A total of 100 patients with inguinal hernia underwent surgery were included in this study. Samples were selected by convenient technique. Among them 50 patients were selected for Desarda Technique was considered as group I and the rest 50 patients were selected for Lichtenstein Mesh Hernioplasty was considered as group II. Statistical analysis of the results was obtained by using window-based computer software devised with Statistical Packages for Social Sciences (SPSS-22). Results: The proposed sample size was 50 in each group. The study group included male patient above 18 years of age undergoing Desarda Technique and Lichtenstein Mesh Hernioplasty for inguinal hernia repair. The mean age was 43.14±14.44 years in group I and 48.33±12.63 years in group II. Indirect hernia was found 37(74.0%) and 28(56.0%) in group I and group II respectively. The mean 3rd POD pain (NPRS) was 4.44±0.97 in group I and 5.52±0.71 in group II. The mean 10th POD pain Numeric Pain Rating Scale (NPRS) was 0.76±1.02 in group I and 2.62±1.21 in group II. The mean 1 month pain (NPRS) was 0.08±0.27 in group I and 0.72±0.7 in group II. The mean 3rd month pain (NPRS) was 0.02±0.14 in group I and 0.34±0.48 in group II. The mean 6th month pain (NPRS) was 0±0 in group I and 0.2±0.45 in group II. Pain (NPRS) was significantly (p<0.05) higher in group II in 3rd POD and all subsequent follow-up. Seroma was found 5(10.0%) at 10th POD in group I and 5(10.0%) in group II. The difference was statistically not significant (p>0.05) between two groups. Wound infection found 2(4.0%) in 3rd POD in group Iand 5(10.0%) in group II. Wound infection didn’t develop in subsequent follow-up in group I but in group II, 1(2.0%) found in 10th POD, 1(2.0%) in 1 month, 1(2.0%) in 3rd month, 1(2.0%) in 6th month. The difference was not significant (p>0.05) between two groups. Recurrence was not observed in either group during this study period. Conclusion: Desarda technique of inguinal hernia repair in our set up is useful with comparable results to Lichtenstein hernioplasty. IAHS Medical Journal Vol 7(1), June 2024; 91-96

BN SO34 - Outcomes in giant versus non-giant hiatus hernia repair: Same payment different operative burden

Abstract Background Hospital trust payment for operative procedures often rely on coding systems like the NHS's Office of Population Censuses and Surveys (OPCS) codes, which determine reimbursement rates. Both giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs often share the same code, as in our trust. This results in equal reimbursement to trusts for procedures with higher operative burden and resource needs. This study aims to assess differences in the patient population, their hiatal type, operative challenges and post-operative outcomes between GHH and NGHH repairs. Method All patients undergoing primary hiatus hernia surgery between March 2019 to March 2024 at a single institution were included. Retrospective review of electronic records were utilised to record: patient demographics, hernia type, operative details, length of stay (LOS), post-operative course and need for a return to theatre (RTT). Outcomes were comparison of surgical approach, use of mesh and gastropexy (as proxy measures to indicate difficulty of operation), 30-day morbidity measured using Clavien-Dindo (CD) grading and 30-day mortality and RTT. Analysis was undertaken using un-paired t-test and Chi2. A p-value of <0.05 was considered statistically significant. Results Table 1. Patients GHH NGHH p n 91 135 Age (average) 69 (±10) 52 (±16) <0.001 Female (%) 66.7 55.2 0.1100 BMI 30.8 (±5.4) 30.7 (±7.8) 0.2029 ASA grade (average) 2.2 1.9 <0.001 Hernia Types (median) 3 1 <0.001 Table 2. Operative details GHH NGHH p Open (%) 6.6 0 0.0020 Laparoscopic (%) 60.4 62.24 0.9840 Robotic (%) 33 33.3 0.9239 Mesh used (%) 8.8 0.7 <0.041 Gastropexy (%) 12 0.7 <0.001 Table 3. Outcomes GHH NGHH p LOS (median) 2 (0-161) 1 (0-8) 0.0179 RTT (%) 10.7 8 0.4747 30-day morbidity (CD≥3, %) 4.8 4.4 0.6519 30-day mortality 0 0 NA Conclusion This study highlights significant differences between giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs. GHH repairs have an increased likelihood of undergoing open procedures, use of mesh, and gastropexy, reflecting their greater complexity. GHH patients are older, have higher ASA grades, and present with more advanced hernia types compared to NGHH patients. Additionally, GHH repairs result in longer hospital stays. The findings underscore the need for improved coding accuracy to reflect these disparities accurately in patient demographics, operative strategies, and recovery outcomes within hospital trusts, ensuring appropriate resource allocation and reimbursement based on procedural complexity.

BN SO58 - Patient Reported Outcome Measures in Hiatal Surgery: A Feasibility Study

Abstract Background Hiatal surgery is predominantly a quality-of-life procedure rather than a lifesaving intervention. Whilst procedural complications are well understood, they do not necessarily reflect the patient experience. Traditional indicators of patient care are insufficient. Patient Reported Outcome Measures (PROM) are robust indicators of care quality (1) and are being used across surgical specialities to benchmark success and identify areas for improvement (2). We present a three-year review of our PROM data to demonstrate feasibility of data collection. Method Patient reported outcome measure data were collected from the National Hiatal Surgery Registry (3) for our benign centre over a three-year period (November 2021-January 2024). Consent was obtained from all patients for research purposes. Surgical procedures included: anti-reflux surgery, hiatus hernia repair and cardiomyotomy. All patients were asked to complete pre-operative quality of life surveys. Patients are automatically contacted through the registry at 6months, 1 year and then annually for five years and prompted to complete quality of life surveys. Ekhardt score is used in achalasia. GORD-QoL score was used for anti-reflux procedures, with the Hernia-QoL score for hiatal hernia. Results Data were collected for 20 patients. Mean BMI was 28.2. All completed preoperative surveys. At six months there was attrition of one patient, who has since completed 1-year and 2-year data. At the time of writing, six patients have completed 6month data, 5 patients have completed 1-year data and 3 patients have completed 2-year data. Mean Ekhardt score was 9.25 preoperatively; at six months mean score was 0. Five patients underwent LINX, eleven underwent fundoplication; one Dor, ten Toupet. Mean pre-operative quality of life score was 31.1; at six months mean score was 15.5. At one year this was 4. Conclusion The National Hiatal Surgery Registry facilitates easy acquisition of surgeon specific PROM data over a short- and long-term period. Patient attrition is low, demonstrating acceptability. Our data demonstrate significantly improved patient reported quality of life postoperatively for all hiatal surgery.

Laparoscopic transabdominal vs. totally extraperitoneal inguinal hernia repair: outcomes, healthcare utilization, and cost differences

Laparoscopic transabdominal vs. totally extraperitoneal inguinal hernia repair: outcomes, healthcare utilization, and cost differences

Association of DCI with number of preoperative comorbidities and 30-day outcomes following inguinal hernia repair: an analysis of the ACHQC database

Association of DCI with number of preoperative comorbidities and 30-day outcomes following inguinal hernia repair: an analysis of the ACHQC database

HPB SO14 - Surprise Inside: Gallbladder Herniation in a Parastomal Hernia - A Rare Case Report and Management Insight

Abstract Background Parastomal hernias are a common complication of stoma formation, affecting approximately 40% of patients within two years. Gallbladder herniation within a parastomal hernia is a rare phenomenon, with only 18 cases previously reported. Patients are typically elderly females, with the condition attributed to ageing factors such as loss of visceral fat and elastic tissue, liver shrinkage, and the increased length and loss of elasticity of the gallbladder mesentery. These factors contribute to visceroptosis of the gallbladder, increasing its mobility and the risk of herniation. Method We present the case of a 68-year-old female with a four-day history of severe parastomal hernia pain and swelling. She had an emergency left hemicolectomy and transverse colostomy in the right upper quadrant 10 years prior for ischaemic colitis and perforation. Her stoma was functioning well. Vital signs and biochemistry results were normal. On examination her hernia was severely tender but partially reducible. CT revealed a right upper abdominal parastomal hernia containing loops of colon and surprisingly the gallbladder with a long stretched cystic duct. There was no evidence of cholecystitis, bowel obstruction, or compromise within the hernial sac. Results With analgesia, the patient's pain improved, though her hernia remained irreducible. She was discharged after two days of conservative management and referred back to the hospital where she had the initial operation. On enquiry with that hospital it was reported that an elective parastomal hernia repair with completion right colectomy and end ileostomy was performed. The gallbladder was mobilised and reduced back into the peritoneal cavity, and the hernial defect was closed. The patient made an excellent recovery and was discharged home three days after surgery. Conclusion Cholecystic parastomal herniation is a very rare phenomenon and should be considered as a differential in similar cases. Management should be based on clinical presentation, radiological diagnosis, and a multidisciplinary team approach. No standardised classification or approach exists. We propose classifying gallbladder herniations as either being simple (without inflammatory sequelae) or complicated (with cholecystitis, gallbladder torsion, incarceration or perforation). Simple herniations, such as the case presented, can be managed electively with intra-operative reduction of the gallbladder sufficing. Complicated herniations during acute admissions indicate the need for emergency surgical intervention with combined cholecystectomy and parastomal hernia repair.

BN SO10 - Virtual Reality in Acute Pain Management of Adult Surgical Patients: Literature Review

Abstract Background Pain is an unavoidable side effect of medical procedures. British Pain Society (BPS) reports almost 10 million people in UK suffer from pain everyday. BPS reported an estimated €5 million per year is spent on managing back pain alone. Pharmaceutical pain management is costly and can cause side effects. Virtual Reality (VR) is a novel technology used to alleviate pain. We performed a literature review to assess the current advances in the pain management using VR. Method A literature search was done on the use of VR for pain management across 4 databases (Pubmed, Medline, Embase and Cinahl) using key words virtual reality, acute pain, adult, surgery. 144 non-duplicated studies were found. 66 studies were excluded: 41 were non-acute pain related, 16 involved chronic pain, 9 involved paediatric population. 78 studies with the total number of 1514 patients (n=1514) were included. All studies used VR to relieve acute pain symptoms experienced while undergoing a procedure. The data included sample size, gender, age, specialty, VR type, pain scale, pain score before and after, interventions, key findings and limitation. Results VR was tested to control pain in general surgery, plastics, obstetrics and gynaecology, cardiothoracics, orthopaedics, urology, and dentistry. In benign UGI surgery, including fundoplication, paraesophageal hernia repair, esophageal myotomy, and pyloroplasty requiring an overnight stay, the use of VR reduced pain, anxiety and nausea. Overall, no adverse outcomes were reported. No difference in nausea and dizziness between VR and control groups was observed. Active software has been shown to be superior to the passive one. Complete immersion with visual and audio stimulation replaced by VR environment is important. The results were similar in different age groups. Conclusion There is a good body of evidence to support the use of VR in pain management in clinical practice. It acts as a good distraction tool. The use of VR was demonstrated to be beneficial in reducing postoperative pain in benign UGI surgery. However, the main areas of application would be in short procedures where it not only delivers better pain management but also increases patient satisfaction and decreases the need for pharmaceutical analgesia, thus bringing down the overall cost.