Acute Kidney Injury After Large Ventral Hernia Repair Requiring Transversus Abdominis Release

Background Acute kidney injury (AKI) is a known postoperative complication of open ventral hernia repair contributing to increased costs, hospital length of stay, and mortality. The aim of this study was to identify whether the muscle injury that occurs in a posterior separation of components via transversus abdominis release (TAR) contributes to a higher incidence of postoperative AKI. Methods A retrospective cohort study of patients who underwent open retrorectus ventral hernia repair with and without TAR at a single institution between 2012 and 2019 was performed. Patients who underwent a separation of components via either unilateral or bilateral transversus abdominis release were compared to those who did not undergo TAR as part of their hernia repair (non-TAR). The outcome of interest was the development of postoperative AKI. Acute kidney injury was defined as an increase in creatinine of greater than 50% of the preoperative baseline. Univariate and multivariate analyses were performed to determine the influence of TAR on the development of AKI. Results There were 523 patients who met inclusion criteria, of which 159 (30.4%) had a TAR as part of their retrorectus hernia repair. No differences were found in preoperative characteristics between the TAR and non-TAR group including age, gender, history of kidney disease, or history of diabetes. By contrast, the TAR group had significantly greater median estimated blood loss (100 mL vs 75 mL, P < .01), mean positive intraoperative fluid balance (2255 mL vs 1887 mL, P < .01), and operative duration (321 min vs 269 min, P < .001). The rate of AKI in the TAR group was 11% (n = 18) vs 6% (n = 23, P = .0503) in the non-TAR group. On multivariate analysis controlling for patient characteristics and intraoperative factors, TAR was the only factor with a significantly increased odds of AKI (OR 1.97, 95% CI 0.994-3.905, P = .0521). Conclusions In patients with large ventral hernias requiring retrorectus repair, performing a TAR is associated with a nearly 2-fold increase in the development of postoperative AKI. These findings suggest that these patients should be optimized perioperatively with emphasis on fluid resuscitation, limiting nephrotoxic medications and monitoring urine output.

O28 APPLICATION OF MICROPOROUS POLYSACCHARIDE HEMOSPHERES DURING TRANSVERSUS ABDOMINAL RELEASE TO REDUCE SEROMAS AND HEMATOMAS

Aim Wound complications, like seromas and hematomas, occur in 23% after transversus abdominis release (TAR). Hemostat agents like fibrin glue have potential to reduce this rate, by vessel sealing and tissue bonding. But these are expensive. A topical hemostatic, like microporous polysaccharide hemospheres (MPH), is much cheaper, but its potential to reduce seromas and hematomas has never been analyzed in ventral hernia surgery. Material and Methods After the first 25 consecutive TAR patients (Control group, 2016-2018), MPH was introduced as an adjunct in a consecutive group of 25 TAR patients (Intervention group, 2019-2020). MPH was sprinkled in the TAR planes and subcutaneous tissue. Groups were compared. Results Pre-operative base-line characteristics and the overall complexity of the hernia patients and operations did not differ between the two groups. Postoperatively, the overall rate of surgical site occurrences (SSO) differed (CG:60%;IG:32%), but not significantly. Seromas (CG:5%;IG: 3%) and hematomas (CG:28%;IG:8%) did not differ significantly between the two groups. Medical complications (CG:13%;IG:10%) and two-year recurrence rate (CG:12%;IG:16%) also did not differ. Conclusions This study did not demonstrate a clear effect of MPH on the incidence of SSO, seromas or hematomas after a transversus abdominis release, despite the high incidence of wound complications in the first group of TAR patients (presumably, reflecting the learning curve of TAR). The fact that MPH does not glue tissue layers and minimize dead space, may be causative. MPH is not advised as an adjunct to reduce SSO.

P019 OUTCOMES OF OPEN LATERAL APPROACHES FOR L3-L4 INCISIONAL HERNIAS

Aim Our study aimed to compare and evaluate results of two different open lateral approaches for L3–L4 incisional hernias (IH) operated in a multicentric complex abdominal wall unit. Material and Methods Patients who underwent surgery for L3–L4 IH were identified from a prospective maintained multicenter database. The lateral IH were approached laterally, performing a reverse transversus abdominis release (TAR) or a lateral retromuscular preperitoneal approach (LRP). Outcomes included short and long-term complications, such as recurrence, bulging and pain. Results 61 patients were identified. There were 28 (45.9%) cases of L3 IH and 33 (54.1%) cases of L4 IH. 28 (34.7%) LRP approaches and 33 (24.5%) reverse TAR techniques were performed. There were surgical site occurrences (SSO) in 13 (21.3%) patients, 7 (11.5%) in the reverse TAR group and 6 in the LRP group. 8 (13.1%) SSO required procedural intervention (4 in each group). During a mean follow-up of 26.57 (+/- 19.23) months, no cases of recurrence were diagnosed. There were 12 (19.7%) cases of asymptomatic bulging that did not required reintervention (7 in the LRP group), and only one case of symptomatic bulging that needed intervention (in the LRP group). Furthermore, two patients (3.3%) required daily no opioids treatment for pain. Two (3.3%) cases of mortality were registered (both in the LRP group). Conclusions Despite the high complexity associated of L3-L4 IH, both lateral approaches showed acceptable long-term results, without any statistical difference between groups.

P028 COMBINING SEVEN ITEMS OF THE TOOLBOX TO TREAT A LARGE INCISIONAL HERNIA WITH HETEROTOPIC OSSIFICATION: A CASE REPORT

Aim We present our approach of treating a W3 (EHS-Classification) incisional hernia with heterotopic ossification in the abdominal wall. Material and Methods a 62-years-old female patient presented with a hernia in her inverted-T incision (midline and transverse) after undergoing multiple laparotomies. The CT-scan showed calcified structures within the abdominal wall. We planned the extensive reconstruction after preoperative Botox injections. Results The 20x25 cm hernial sack contained parts of the stomach and colon. The dissection of the midline and transverse scars was challenging with the needed removal of scattered pieces of heterotopic bone tissues. After dissecting the retro-muscular space, the fascial edges were 25 cm apart. With bilateral transversus abdominis release (TAR), It was reduced to 20 cm. The posterior fascia was approximated, leaving a central 12 cm defect, and a smaller lateral defect, which we covered using open-IPOM and underlay techniques respectively. A 30x40 cm mesh in sublay position was placed and fascial traction was applied on the anterior fascia. With the resulting defect of 16 cm, a tension-free closure was still not possible, and we bridged the gap with a mesh in inlay position. Conclusions Despite combining pre-operative Botox injection and fascial traction with TAR, complete closure of the fascia was not possible. IPOM, sublay, underlay and inlay bridging were needed. Specialized hernia surgeons should be familiar with a wide range of different techniques to deal with such cases.

P085 CLINICAL AND LONGITUDINAL PATIENT REPORTED OUTCOMES AFTER TRANSVERSUS ABDOMINIS RELEASE: A SINGLE SURGEON EXPERIENCE

Aim Posterior component separation with transversus abdominis release (TAR) is a novel complex abdominal wall repair technique that maximizes medial myofascial flap advancement in a vascularized, pre-peritoneal plane. Here, we add to a growing body of literature on this technique by assessing longitudinal clinical and patient reported outcomes (PROs) after ventral hernia repair (VHR) with TAR. Material and Methods Adult patients undergoing VHR with TAR between 10/1/2015 and 01/15/2020 by a single surgeon were retrospectively identified. Patients with parastomal hernias and &lt;12 months of follow-up were excluded. Clinical outcomes and PROs using the Abdominal Hernia Questionnaire (AQH) and Hernia Related Quality of Life Survey (HerQLes) were assessed. Results 57 patients were included with a median age and body mass index of 60 and 30.6 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retro-muscular mesh placed. The most common complications were delayed healing (19.3%) and seroma (14.0%). One patient required return to the OR for management of a complication and there were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing any complication (p &lt; 0.05). One patient (1.8%) recurred at a median follow-up of 25.7 months [IQR 18.2-42.1]. Significant improvement in disease-specific PROs was observed and maintained throughout the follow-up period (pre to post p &lt; 0.05). Conclusions Longitudinal clinical and patient-reported outcomes after VHR with TAR are limited. We conclude that TAR is a safe and efficacious adjunct in the repair of complex hernia defects.

P005 POSTERIOR COMPONENT SEPARATION WITH TRANSVERSUS ABDOMINIS RELEASE FOR COMPLEX VENTRAL HERNIA REPAIR: A CASE SERIES

Aim To assess the short- and long-term outcomes of posterior component separation with transversus abdominis release (PCS-TAR) at our Centre. Material and methods From 2016, our abdominal wall unit started with PCS-TAR for the treatment of patients with complex abdominal wall hernias. We report our prospectively collected preliminary results. Results Sixty-six patients underwent PCS-TAR. Twenty patients had already received at least one previous hernia repair, 16 with mesh implantation. The median width of the defect was 12 cm (range 3 - 35), the median length 15 (range 4 - 40). Defects were multiple in 13 cases, swiss cheese in 2 cases. Eleven defects had both a midline and a lateral component, 3 had a concomitant parastomal hernia. Thirty-eight cases were located near the abdominal wall borders. The median duration of surgery was 255 minutes (range 84 - 740). TAR was partial in 24 cases and monolateral in 24. Twelve cases involved previous mesh removal. Fifty patients received implantation of more than one mesh: the most common combination was a PVDF mesh on top of a biosynthetic mesh. The mesh seldom needed to be fixed. The median length of stay was 6 days (range 3 - 61). Postoperative complications occurred in 22 patients (3 were major). Surgical site occurrences happened in 7 cases. After at least 12 months of follow up per patient, there was 1 recurrence, 1 case of chronic pain and no chronic seromas. Conclusions Posterior component separation with transversus abdominis release offers a versatile solution for a variety of complex ventral hernias, with good short- and long-term results.

OV06 EXTENDING THE INDICATIONS OF TRANSVERSUS ABDOMINIS RELEASE: SUBLAY MESH REPAIR FOR A RARE CASE OF ACQUIRED DIAPHRAGMATIC HERNIA

Aim Acquired diaphragmatic hernia (ADH) is rare and its treatment is challenging. Posterior component separation (PCS) with transversus abdominis release (TAR) is gaining wide acceptance for the repair of complex abdominal hernia, including those located in proximity of the abdominal borders. In this view the central tendon of the diaphragm could be intended as the rooftop border of the peritoneal sac. We describe an original application of TAR for the treatment of an unusual case of ADH. Material and Methods a 54 year-old man was referred to our department for an ADH, following two previous sternotomies for an aortic aneurysm, conditioning respiratory symptoms. A thoraco-abdominal contrast enhanced CT-scan confirmed an anterior left diaphragmatic defect with a transverse diameter of 8.5 cm and a huge sac containing the great omentum and the distal transverse colon, with atelectasis of the inferior lobe of the lung. A subxiphoid M1W2L2 incisional hernia was also detected. The patient underwent a midline xipho-umbilical laparotomy and a repair by partial TAR with posterior rectus sheath release and progressive dissection of the diaphragmatic muscular fibers far beyond the DH. A sublay repair with a large dual layer PVDF mesh was then accomplished. Results Postoperative course was uneventful and no recurrence was recorded at 6 months follow up. Conclusions partial-TAR could be a good option for repair of anteriorly placed ADH, ensuring a stable anatomical repair with an overlap that is usually wider than after laparoscopic IPOM repair. This novel indication confirms the extreme versatility of TAR for the repair of complex ventral hernia