Transversus Abdominis Release Research Articles

Comparative Study between Posterior Component Separation with Transversus Abdominis Release and Anterior Component Separation in Management of Large Ventral Abdominal Hernia

Comparative Study between Posterior Component Separation with Transversus Abdominis Release and Anterior Component Separation in Management of Large Ventral Abdominal Hernia

The influence of a multidisciplinary team meeting and prehabilitation on complex abdominal wall hernia repair outcomes.

Surgical site occurrences after transversus abdominis release in ventral hernia repair are still reported up to 15%. Evidence is rising that preoperative improvement of risk factors might contribute to optimal patient recovery. A reduction of complication rates up to 40% has been reported. The aim of this study was to determine whether prehabilitation has a favorable effect on the risk on wound and medical complications as well as on length of stay. A retrospective cohort study was performed in a tertiary referral center for abdominal wall surgery. All patients undergoing ventral hernia repair discussed at multidisciplinary team (MDT) meetings between 2015 and 2019 were included. Patients referred for a preconditioning program by the MDT were compared to patients who were deemed fit for operative repair by the MDT, without such a program. Endpoints were patients, hernia, and procedure characteristics as well as length of hospital stay, wound and general complications. A total of 259 patients were included of which 126 received a preconditioning program. Baseline characteristics between the two groups were statistically significantly different as the prehabilitated group had higher median BMI (28 vs 30, p < 0.001), higher HbA1c (41 vs 48, p = 0.014), more smokers (4% vs 25%, p < 0.001) and higher HPW classes due to more patient factors (14% vs 48%, p < 0.001). There were no significant differences in intra-operative and postoperative outcome measures. This study showed prehabilitation facilitates patients with relevant comorbidities achieving the same results as patients without those risk factors. The indication of a preconditioning program might be effective at the discretion of an MDT meeting. Further research could focus on the extent of such program to assess its value.

Robotic transversus abdominis release: A paradigm shift in complex abdominal wall surgery?

Abdominal wall reconstruction techniques have evolved significantly over the last fifty years and continue to do so at an increasing pace. Beginning with open incisional hernia repair with bilateral rectus myofascial release, multiple techniques to offset tension at the midline by exploring options of layered myofascial release have been described. This article reviews the history, technique, advancements, and future of myofascial release in abdominal wall reconstruction leading from the open Rives-Stoppa repair to the robotic-assisted iteration of the transversus abdominis release.

Management of diastasis recti during ventral hernia repair: an analysis of the abdominal core health quality collaborative.

Advancements of minimally invasive techniques leveraged routine repair of concomitant diastasis recti (DR), as those approaches facilitate fascial plication and wide mesh overlap while obviating skin incision and/or undermining. Nevertheless, evidence on the value of such intervention is lacking. We aimed to investigate the management and outcomes of concomitant DR during ventral hernia repair (VHR + DR) from surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). Patients who have undergone VHR + DR with a minimum 30-day follow-up complete were identified. Outcomes of interest included operative details, surgical site occurrences (SSO), medical complications, and readmissions. 169 patients (51% female, median age 46, median body mass index 31kg/m2) were identified. Most hernias were primary (64% umbilical, 28% epigastric). Median hernia width was 3cm (IQR 2-4) and median diastasis width and length were 4cm (IQR 3-6) and 15cm (IQR 10-20), respectively. Most operations were robotic (79%), with a synthetic mesh (92%) placed as a sublay (72%; 59% retromuscular, 13% preperitoneal). DR was repaired with absorbable (92%) and running suture (93%). Considering our cohort's relatively small diastasis and hernia size, a high rate of transversus abdominis release was noted (14.7%). 76% were discharged the same day and the 30-day readmission rate was 2% (2 ileus, 1 pneumonia). SSO rate was 4% (6 seromas, 1 skin necrosis) and only one patient required a procedural intervention. ACHQC participating surgeons usually perform VHR + DR robotically with a retromuscular synthetic mesh and close the DR with running absorbable sutures. Short-term complications occurred in approximately 6% of patients and were mainly managed without interventions. Larger studies with longer-term follow-up are needed to determine the value of VHR + DR.

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.

The first robotic STORRM: A case report

Abstract Parastomal hernias present a continued challenge to the general surgeon. There are a myriad of techniques available, with hernia recurrence rates varying between 10 to greater than 50%. Mesh reinforcement and underlay or sublay placement are associated with lower hernia recurrence rates. Many patients with parastomal hernia have associated comorbidities which increase their risk for perioperative wound complications. Robotic and minimally invasive techniques offer decreased rate of wound complications, but can be challenging to perform if the stoma needs to be relocated. For patients with complex parastomal hernias requiring abdominal wall reconstruction with transversus abdominis release and retromuscular mesh placement, it can be difficult to align the layers of the abdominal wall and create an aperture in the mesh to allow for a straight passage of the conduit and prevent subsequent angulation of the bowel. Stapled Transabdominal Ostomy Reinforcement with retromuscular mesh, or STORRM technique, has been previously described elsewhere as a technique whereby a circular EEA (End-to-End Anastomoses) stapler is used to create a straight tunnel through the mesh and abdominal wall layers, standardize sizing, fixate the mesh, and substitute traditional cruciate incisions with a stapled reinforcement of the aperture in the mesh/tissues.

Computed tomography for ventral hernia: Need for a standardised reporting format.

Computed tomography for ventral hernia: Need for a standardised reporting format.

The outcome of Transversus Abdominis Release for complex ventral hernia: A one-year of follow-up experience

Introduction: Transversus Abdominis Release is a noble technique for the repair of complex ventral hernia, where the posterior component separation allows a huge pre-peritoneal space advantageous for the placement of large-sized mesh. It has less wound morbidity as compared to anterior component separation due to the preservation of skin perforators. The main objective of this study was to evaluate one-year follow-up results in terms of recurrence, wound morbidity, and various techniques for managing complications of Transversus Abdominis Release. Methods: This is a descriptive crosssectional study that was conducted at the department of surgery, College of Medical Sciences Teaching Hospital. Among 41 patients with complex ventral hernia, 34 patients met the inclusion criteria. Demographic data, intra-operative events like bleeding, operative duration, intraoperative complications, post-operative events like duration of hospital stay, wound morbidity, and follow-up data were analyzed. Results: Posterior rectus sheath closure at midline was possible in 30 (88.2%) patients. In patients, where posterior rectus sheath closure was not possible, the peritoneum of hernia sac was tailored to patch the defect or in some omentum was placed below the raw surface of mesh. The average operative duration and blood losses were 130±12 minutes and 301±133 ml respectively. The semilunar line injury occurred in one case that was diagnosed and repaired at the same time and the TAR plane was re-established. Wound morbidity occurred in three cases that were managed by dressing with commercially available collagen and mupirocin granule. No recurrence was observed in one-year follow-up. Conclusions: Transversus Abdominis Release has a better result with no recurrence in short term follow up and fewer complications which are easily manageable.

Robotic repair of non-midline hernias.

Non-midline abdominal wall hernias present unique anatomic challenges, making repair more complex. The constraints of the peritoneal cavity, pelvis, and costal margin limit the utility of intraperitoneal mesh repair, and extra-peritoneal repairs have traditionally been performed using open techniques, often resulting in higher wound morbidity. Advances in minimally invasive surgery make visualization and dissection of such complex cases feasible, with all the attendant benefits of a minimally invasive over an open approach. In this study, we examined the use of the robotic platform to repair non-midline hernias. Retrospective review of all non-midline abdominal wall hernias was performed robotically at Prisma Health, excluding parastomal hernias. Study conducted and outcomes reported according to STROBE statement. Repair was performed in the retro-rectus (n = 3) or retro-rectus + transversus abdominis release (TAR) (n = 39), pre-peritoneal (n = 22), and intraperitoneal (n = 1). Mean hernia width was 9.4cm, permanent synthetic mesh used for all repairs. Mean LOS was 1.5days. Surgical-site occurrence (SSO) occurred in 49.2%, 78% of which were simple seroma. Three patients (4.6%) developed surgical-site infection (SSI). Two recurrences were identified with a mean follow-up of 11 mos. The robotic platform facilitates complex dissection to allow minimally invasive, extra-peritoneal repair of complex non-midline hernias. This approach overcomes the anatomic constraints of intraperitoneal mesh repair and the wound morbidity of open repair.

Description of the Current Da Vinci® Training Pathway for Robotic Abdominal Wall Surgery by the European Hernia Society.

Background: Robot assisted laparoscopic abdominal wall surgery (RAWS) has seen a rapid adoption in recent years. The safe introduction of the robot platform in the treatment of abdominal wall hernias is important to safeguard the patient from harm during the learning curve. The scope of this paper is to describe the current European training curriculum in RAWS. Methods and Analysis: The pathway to competence in RAWS will depend on the robot platform, experience in other abdominal procedures (novice to expert) and experience in the abdominal wall repair techniques. An overview of the learning curve effect in the initial case series of several early adopters in RAWS was reviewed. In European centres, current training for surgeons wanting to adopt RAWS is managed by the specific technology-based training organized by the company providing the robot. It consists of four phases where phases I and II are preclinical, while phases III and IV focus on the introduction of the robotic platform into surgical practice. Conclusion: On behalf of the Robotic Surgery Task Force of the European Hernia Society (EHS) we believe that the EHS should play an important role in the clinical phases III and IV training. Courses organized in collaboration with the robot provider on relevant surgical anatomy of the abdominal wall and procedural steps in complex abdominal wall reconstruction like transversus abdominis release are essential. Whereas the robot provider should be responsible for the preclinical phases I and II to gain familiarity in the specific robot platform.

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.

Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure.

The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. Hierarchical and cognitive task analyses for a TAR procedure were performed using semi-structured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts (median 66 minutes [44-78]). Subject matter experts practiced a median of 6.5 years [1.5-16] and have completed a median of 300 [60-500] TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure; ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

Posterior component separation with TAR: lessons learned from our first consecutive 52 cases.

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39-76) and Body mass index (BMI kg/m2) of 31.2 (24-45). More than half of patients (58%) were active smokers. Mean defect width was 13.6cm (range 6-30) and mean defect area was about 267.9cm2. Mean operative time was 228min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7days. 27% of patients developed minor complications (Clavien-Dindo grade I-II) and one case (1.9%) major complication (Clavien-Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28months. In Univariate analysis Bio-A surface > 600cm2 and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600cm2 was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien-Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients.

Analysis of Factors Associated with Same-Day Discharge After Robotic Transversus Abdominis Release for Incisional Hernia Repairs.

Background: Advancement in surgery has shifted numerous procedures to a same-day discharge (SDD) setting. In this study, we evaluated factors related to SDD after robotic transversus abdominis release (rTAR). Materials and Methods: A retrospective analysis of a prospectively maintained hernia databank was performed. Patients who underwent rTAR for incisional hernias were assigned to either the SDD group (length of stay [LOS] <1) or the inpatient group (LOS ≥1 day). Pre-, intra-, and postoperative variables were compared. Predictors of SDD were explored through a logistic regression, and a mediation analysis was performed to assess their effect on the LOS. Results: Out of the 167 patients included, 53 patients were discharged the same day. Age, American Society of Anesthesiologists score, history of coronary artery disease, and wound infection were significantly higher in the inpatient group. Overall, median LOS was 1 (0-2). Postoperative complications did not differ between SDD and inpatient groups except for Clavien-Dindo Grade-II (1 versus 14, respectively; P = .039). Thirty-day readmission rates were comparable (P = .229). A binary logistic regression to predict factors associated with SDD rTAR showed statistical significance in age, operative time, mesh area, and history of wound infection. Mediation analysis showed that mesh size indirectly affected the LOS through the operative time (a = 0.54; b = 0.46; P < .001). An age >46-year-old, an operative time beyond 217 minutes, and a mesh size >475 cm2 increased the probability of an inpatient stay (area-under-the-receiver operating characteristic curves: 0.69, 0.81, and 0.82, respectively). Conclusion: The pre- and intraoperative factors associated with SDD rTAR were age, history of wound infection, operative time, and mesh area. Further studies are needed to investigate the appropriateness of discharge decisions while balancing patients' benefits, resource utilization, and costs.

Transversus abdominis release (TAR) procedure: a retrospective analysis of an abdominal wall reconstruction group

Complex abdominal wall defects are important conditions with high morbidity, leading to impairment of patients' physical condition and quality of life. In the last decade, the abdominal wall reconstruction paradigm has changed due to the formation of experienced and excellence groups, improving clinical outcomes after surgery. Therefore, our study shows the perspective and outcomes of an abdominal wall reconstruction group (AWRG) in Colombia, focused on the transverse abdominis release (TAR) procedure. A retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent TAR procedures between January 2014–December 2020 were included. Analysis and description of postoperative outcomes (recurrence, surgical site infection (SSI), seroma, hematoma, and re-intervention) were performed. 47 patients underwent TAR procedure. 62% of patients were male. Mean age was 55 ± 13.4 years. Mean BMI was 27.8 ± 4.5 kg/m2. Abdominal wall defects were classified with EHS ventral Hernia classification having a W3 hernia in 72% of all defects (Mean gap size of 11.49 cm ± 4.03 cm). Mean CeDAR preoperative risk score was 20.5% ± 14.5%. Preoperative use of BOTOX Therapy (OR 1.0 P 0.00 95% CI 0.3–1.1) or pneumoperitoneum (OR 0.7 P 0.04 95% CI 0.3–0.89) are slightly associated with postoperative hematoma. In terms of hernia relapse, we have 12% of cases; all of them over a year after the surgery. TAR procedure for complex abdominal wall defects under specific clinical conditions including emergency scenarios is viable. Specialized and experienced groups show better postoperative outcomes; further studies are needed to confirm our results.

Retromuscular drain versus no drain in robotic retromuscular ventral hernia repair: a propensity score-matched analysis of the abdominal core health quality collaborative.

Drains may be placed during robotic retromuscular ventral hernia repair (rVHR) to decrease wound morbidity, but their use is controversial. We aimed to assess the impact of retromuscular drain placement on wound morbidity after robotic rVHR. Patients with and without drains after robotic rVHR in the Abdominal Core Health Quality Collaborative (ACHQC) registry were compared using a propensity score-matched analysis. Outcomes included surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrences requiring procedural interventions (SSOPI) at 30days. Propensity score matching compared 580 patients with drains to 580 without drains. The groups were well matched with respect to hernia width (drain: 8.0cm [IQR 6.0; 10.0] vs no drain: 8.0cm [IQR 5.0; 10.0]; P = 0.399) and transversus abdominis release (drain: 409 (70.5%) vs no drain: 408 (70.3%); P = 0.949). At 30days, patients with drains had fewer seromas than those without drains (22 (3.8%) vs 88 (15.2%); P < 0.0001). Rates of SSIs and SSOPIs were similar between the two groups at 30days. Logistic regression analysis showed drain placement lowered the risk of an SSO compared to no drain placement (OR 0.32, CI 0.21-0.47; P < 0.0001). Hospital stay was longer for patients with drains than those without drains (2.0days [IQR 1.0; 3.0] vs 1.0day [IQR 1.0; 2.0], respectively; P < .0001). Drain placement during robotic rVHR is associated with decreased postoperative seroma occurrence.

Robot-assisted extraperitoneal ventral hernia repair-Experience from the first 61 consecutive operations with eTEP and eTAR techniques

As in many other fields of surgery, robotically assisted surgical procedures have been established in the treatment of ventral hernias in recent years. The use of the robot can combine the demands of a minimally invasive approach and retromuscular mesh placement. In addition to a transabdominal approach, these procedures can also be performed using an extraperitoneal approach. The purpose of this study is to demonstrate that robotic total extraperitoneal management of abdominal wall hernias is safe and efficient. A retrospective analysis of all robotically operated patients on ventral hernia using extraperitoneal eTEP technique from September 2019 to May 2022 was performed. A total of 61 ventral hernias were operated on using the robotic eTEP technique during the study period. In 14 patients retro-rectal dissection was extended laterally by an extraperitoneal transversus abdominis release (eTAR) because of the hernia size or a lateral hernia localization. In all cases, an uncoated synthetic mesh was placed in the retromuscular position with complete closure of the hernia defects. The median hernia defect area was 30 cm² (4-308 cm²). The median mesh size was 540 cm² (300-1350 cm²). The median mesh defect ratio (MDR) was 17.78 (3.06-145). One intraoperative and three postoperative complications were encountered. Neither conversion nor reoperation were required. The robotic extraperitoneal eTEP technique enables the required retromuscular mesh placement in a minimally invasive approach. With the possibility of a combination with a transversus abdominis release, even complex findings can be treated using this technique.

Endoscopic Anterior Component Separation and Transversus Abdominus Release are not Associated with Increased Wound Morbidity Following Retromuscular Incisional Hernia Repair.

Traditional anterior component separation during incisional hernia repair (IHR) is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence (SSO) compared to IHR without component separation (CS). This was a retrospective single-center cohort study of patients undergoing open retromuscular IHR comparing patients with or without the use of CS. Retromuscular mesh repair was performed in all patients, and CS was obtained by eACS or TAR. The primary outcome was 90-day incidence of postoperative SSO. Secondary outcomes included length of stay (LOS), 90-day readmission, 90-day reoperation rate and 3-year recurrence rate. A total of 321 patients underwent retromuscular repair, 168 (52.3%) of whom received either eACS or TAR. The addition of eACS or TAR was associated neither with development of SSO (odds ratio: 1.80, 95% confidence interval: 0.94-3.46, P = 0.077) nor with hernia recurrence (hazard ratio 0.77, 0.26-2.34, P = 0.648). There was no significant difference between the groups regarding the frequencies of 90-day readmission or 90-day reoperation. eACS or TAR as adjuncts to open retromuscular IHR were not associated with increased wound morbidity or hernia recurrence.

OC-024 MINIMALLY INVASIVE TREATMENT OF COMPLEX INCISIONAL/VENTRAL HERNIAS USING BOTULINUM TOXIN COMBINED WITH ROBOTIC SURGERY: ROBOTOX PROTOCOL

Abstract Introduction Incisional/ventral hernia repair has changed in the last 20 years. Posterior component separation like TAR (transversus abdominis muscle release) has increased as a revolutionary technique. On the other hand, the use of botulinum toxin (BT) has allowed better closure defect with no tension. We present a preliminary original protocol named ROBOTOX for complex incisional /ventral hernia repair that combined BT and robotic surgery to minimize the TAR procedure. Material and methods BT (Dysport®) was administered in patients with a complex incisional hernia repair and a transverse defect ≧8cm one month before robotic surgery. Demographic variables (age, sex, BMI), EHS classification, need of TAR, size transverse defect, postoperative complications and recurrence were studied. All patients had a previous CT scan. Results Five patients were included in ROBOTOX protocol, 3 men and 2 women with a median age of 63±8, median BMI of 32±3. Four patients had a M3W3 and one a L3 W2 hernia. Median size defect of 11,2±2. Three of them only needed Rives technique, one a unilateral TAR and one a 5 cm dissection of bilateral TAR. At the moment, with a FU of 6±2 months, no recurrences have been reported. Conclusions Robotic surgery combined with BT would allow a downstaging treatment in patients with complex incisional/ventral hernias. A major cases and long term follow up is needed to better conclusions.

P-111 TAR (TRANSVERSUS ABDOMINIS MUSCLE RELEASE) AS AN ALTERNATIVE IN PATIENTS WITH INCISIONAL HERNIA AND COMPLEX ABDOMINAL WALL. ANALYSIS OF OUR EXPERIENCE

Abstract Aim To analyze the results of patients with complex abdominal wall surgery using TAR(transversus abdominis muscle release) technique in our center. Material and Methods An observational, descriptive, retrospective study of patients operated using TAR technique in a second level hospital in the last three years was carried out. Demographic variables, classification of incisional hernias according to the EHS(European Hernia Society), and complications after the intervention were recorded. Statistical analysis was performed with IBMSPSS-Statistics-25. Results 13 patients were operated using TAR. Medium age was 56 years. 54% of patients were men and 46% women. Median BMI was 30. According to the EHS classification, the most frequent incisional hernia was M3(84.6%), followed by M4(61.5%) and M2(53.8%). W2(61.5%) and W3(30.8%). Median distance between the rectus in the CT prior the intervention was 85 mm. 100% had median laparotomy. 53.8% subcostal or stomal incision. 46% of the patients suffered some type of complication, 38.5% surgical. The complications were wound dehiscence secondary to skin necrosis(23%), abscess(15%), mesh infection(7%), hematoma(7%). Recurrence(7%). Subcostal or other laparotomy showed higher risk of complications of any type(p 0,048). Distance between rectums was associated with high risk of skin necrosis and wound dehiscence(p 0,015). No ileus, UTI, pneumonia, stroke or DVT. Conclusions TAR is a technique used in complex abdominal wall with good results in relation to closure of hernia defect. However, in our cohort some postoperative complications were observed with a low rate of hernia recurrence. This highlights the effectiveness of TAR as a technique for complex abdominal wall closure.