PREVENTION OF INCISIONAL HERNIA AFTER OPEN HEPATO-PANCREATO-BILIARY SURGERY: A SYSTEMATIC REVIEW

Introduction Most hepato-pancreato-biliary (HPB) procedures are still performed through open approach. Incisional hernia (IH) is one of the most common complications after open surgery. To date, published data on IH after HPB surgery are scarce, therefore the aim of this study was to assess the current evidence regarding incidence, risk factors, and prevention. Methods Medline/PubMed (1946-2020), EMBASE (1947-2020), and the Cochrane library (1995-2020)) were searched for studies on IH in open HPB surgery. Animal studies, editorials, letters, reviews, comments, short case series and liver transplant, laparoscopic or robotic procedures were excluded. The protocol was registered with PROSPERO (CRD42020163296). Results A total of 5 079 articles were retrieved. 8 studies were finally included for the analysis. The incidence of IH after HPB surgery ranges from 7.7% to 38.8%. The identified risk factors were body mass index, surgical site infection, ascites, Mercedes or reversed T incisions and previous IH. Prophylactic mesh might be safe and effective. Conclusions IH after open HPB surgery is still an important matter. Some of the risk factors are specific for the HPB operations and the incision type should be carefully considered. Randomised controlled trials are required to confirm the role of prophylactic mesh after HPB operations.

PROphylactic MESH (PROMESH) for stoma closure: does it reduce the incidence of incisional hernia? Protocol for a triple-blinded randomised controlled trial

IntroductionApplication of a prophylactic mesh during stoma closure was shown to reduce the incidence of incisional hernia at the site of stoma closure. Our objective is to provide high quality evidence to validate this finding.Methods and analysisThe study will be a randomised controlled triple-blinded superiority parallel monocentric trial. Patients undergoing elective ileostomy or colostomy closure after surgery for digestive cancer will be eligible for inclusion. Patients allergic to the mesh, immunosuppressed or refusing to participate will be excluded. Randomisation will be performed based on a 1:1 allocation ratio between stoma closure with application of a non-absorbable mesh in the sublay position (intervention) and stoma closure without a mesh (control). The primary outcome will be the 1-year incidence of incisional hernia at the site of stoma closure, determined clinically and by CT. Secondary outcomes will be the 31-day incidence of surgical site infection and the modified Carolinas Comfort Scale. Patients, radiologists and investigators performing the assessment at 1 year will be blinded for the allocated study group. Analysis will be performed in intention-to-treat. The trial will include 68 patients (34 with mesh, 34 without mesh).Ethics and disseminationThe present randomised controlled trial was registered into clinicaltrials.gov (NCT 04510558) and was accepted by the local ethic committee (Geneva, Switzerland: CCER 2021-00053). The results will be presented at national and international congresses in the fields of colorectal surgery and general surgery, and published in a peer-reviewed journal.

When to use a prophylactic mesh after stoma closure: a case–control study

Purpose The closure of a stoma is frequently associated with an acceptable morbidity and mortality. One of the most frequent complications is incisional hernia at the stoma site, which occurs in 20%–40% of cases, higher than incisions in other parts of the abdomen. The objective of this study was to identify the risk factors associated with the presentation of incisional hernia after stoma closure, this in order to select patients who are candidates for prophylactic mesh placement during closure. Methods An unpaired case–control study was conducted. This study involved 164 patients who underwent a stoma closure between January 2014 and December 2019. Associated factors for the development of incisional hernia at the site of the stoma after closure were identified, for which it was performed a logistic regression analysis. Results 41 cases and 123 controls were analyzed, with a mean follow-up of 35.21 ± 18.42 months, the mean age for performing the stoma closure was 65.28 ± 14.07 years, the most frequent cause for performing the stoma was malignant disease (65.85%). Risk factor for the development of incisional hernia at the stoma site after its closure was identified as a history of parastomal hernia (OR 5.90, CI95% 1.97–17.68). Conclusions The use of prophylactic mesh at stoma closure should be considered in patients with a history of parastomal hernia since these patients present a significantly higher risk of developing a hernia.

P001 IS PROPHYLACTIC MESH IS ROUTINELY REQUIRED FOR STOMA CONSTRUCTION? IDENTIFICATION OF THE ‘TARGET GROUP’

Background Evidence to support routine prophylactic mesh insertion during stoma construction is conflicting. The PREVENT randomised controlled trial (RCT) suggested lower incidence of parastomal hernia (PSH) with prophylactic mesh but with no quality of life or cost benefit. Another two RCTs has shown no prophylactic benefit (STOMAMESH & STOMA-const). Although European Hernia guidelines recommends routine prophylactic mesh in end-colostomy, NICE guidelines suggest mesh on individual basis not routinely. Aim To identify the group with higher risk to develop a symptomatic PSH when prophylactic mesh should be considered Material and Methods A single center retrospective review of all stoma formed. Younger patient than 18 years and patients who had less than 6 months’ follow-up were excluded. Development of PSH was confirmed by radiological evidence or direct intra-operative visualization Results 194 patients between January 2015 till December 2019 were included with mean follow-up of 15.7±13.5 months where 91 patients developed PSH. On multivariate analysis, older age (>65) (OR 2.3, 95% CI 1.08 – 4.99, p 0.03) and Obesity (OR 5.8, 95% CI 2.53 – 13.57, p 0.00) were risk factors of developing PSH. Among the PSH group, 28 were symptomatic (31%). Symptomatic subgroup had higher ASA (ASA >2) than asymptomatic subgroup (50% Vs 27%, p 0.05) Conclusions Obese patients older than 65 years are at increased risk of PSH. IF their ASA >2 this PSH is likely to become symptomatic. This is the group who should benefit the most from prophylactic measures including mesh insertion and should be targeted for future trials

OV18 ENDOSCOPIC RETRO-MUSCULAR REPAIR OF PARASTOMAL HERNIA - A TANTALIZING NEW TECHNIQUE

Development of retro muscular space with transversus abdominis release has reached maturity in endoscopic surgery. Next-level reconstruction is adaptation to parastomal hernia repair alone or in conjunction with another abdominal wall hernia repair. We aim to present this extraperitoneal modified mesh technique based on the Sugarbaker principle with video demonstration and share clinical data and results from twenty-four patients operated with this technique within two years from the spring of 2019 to the spring of 2021. 77% patients had para-colostomy hernia and 41% of the patients had accessory repairs for midline or opposite flank hernia. 18% had prophylactic mesh at index operation, 27% were recurrent parastomal hernia and ostomies were formed median 32 months prior to parastomal hernia repair. 72% of the patients were operated robotically and 28% laparoscopically. Median follow up at time for presentation will be 17 months.

Implementing a protocol to prevent incisional hernia in high-risk patients: a mesh is a powerful tool

Purpose The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes. Methods Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB. Results A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008–0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65–0.91; P < 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255–0.494; P < 0.0001) and IH (OR 0.394; 95% CI 0.24–0.61; P < 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29–32.39; P < 0.0001). Conclusion Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

P106 PROPHYLACTIC MESH FOR PREVENTION OF INCISIONAL HERNIA IN HIGH-RISK PATIENTS: PVDF “VISIBLE” MESH BEHAVIOUR ON MRI

Aim According to the guidelines, prophylactic mesh placement appears to be an effective, safe procedure in high-risk patients for the prevention of incisional hernia (IH) after midline laparotomy, without its use being standardized. Knowing its radiological behaviour can resolve doubts about its use. Material and Methods This was a prospective observational cohort study. The included patients needed to have more than one risk factor for IH (age&gt; 60 years old, Body Mass Index &gt; 30kg/m2, diabetes, chronic bronchopathy, heart disease, smoking, kidney disease, neoplasia, liver disease, immunosuppression or an emergency operation). Follow-up included 6-week and 12-month postoperative magnetic resonance imaging (MRI). If MRI was not performed, we used the follow-up computed tomography (CT). Results Between July 2016 and March 2021, 54 patients were enrolled in the study. Surgery was emergent in 14.8% of cases, clean-contaminated in 87% and upper gastrointestinal surgery in 51.9%. A total of 43 MRI and 3 CT at 6-week and 30 MRI and 2 CT at 12-month were carried out. The median of the mesh area were 150.7 vs 150,1cm2 respectively. 91% of cases had the mesh lined to the fascia at 12 months. The bridging in the linea alba was zero in 61% at 6-weeks and 24% at 12-month follow-up, mean 9 vs 19mm (p = 0.001). Conclusions The use of imaging tests to know the postoperative behaviour of a Polyvinylidenfluorid (PVDF) “visible” mesh shows us that there is no mesh contraction at one year or detachment of the fascia, however we observe a significant tendency in the separation of the linea alba.

O26 INFECTIOUS COMPLICATION IN RELATION TO THE PROPHYLACTIC MESH POSITION: THE PRIMA TRIAL REVISITED

Aim Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position. Material and Methods Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure. Results Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group. Conclusions Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

O04 DETERMINING THE EFFECT OF MESH WIDTH AND FIXATION PATTERNS ON THE STRENGTH OF PROPHYLACTICALLY REINFORCED LAPAROTOMY INCISIONS

Aim Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing. Material and Methods In each specimen, a ten centimeter (cm) incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5cm, 3cm, 4cm, 6cm, 8cm) and tack separation (1.5cm, 2cm apart), and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 Newtons (N) to 140N were applied to stimulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed. Results All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4cm mesh specimens (567.51N) than those with suture, 2.5cm, and 3.0cm mesh (all p &lt; 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance. Conclusions Four cm mesh re-enforcement is superior to suture-only and smaller meshes at preserving strength in laparotomy closure in the early stages of healing, but larger meshes (6cm, 8cm) do not provide additional benefit. Meshes with more fixation points may be advantageous, but additional data is needed to make definitive conclusions.

O30 THE INCIDENCE OF INCISIONAL HERNIA AT OSTOMY-REVERSAL SITE

Aim The purpose of this study was to evaluate the rate of incisional hernias at the ostomy site after reversal of the ostomy. Material and Methods We used retrospectively compiled database of patients who had undergone ostomy formation and ist reversal. All patients had their surgery performed between Jan. 2011 and December 2019. Patients history, added by clinical examination and CT-scan were performed in order to identify the incidence of incisional hernias. Different variables, like gender, surgical site infection (SSI) and BMI were evaluated as possible risk factors for hernia occurrence. Results Among totally included 224 patients in the study, 190 of all patients had reversal after loop-ileostomy (85%) and 34 patients had reversal after loop-colostomy (15%). Among all stoma reversal patients, 12,8 % developed incisional hernia at the stoma reversal site (n = 28). The incisional hernia occurrence at the ostomy reversal site was present in 20,0% in patients with clinically relevant SSI and only in 9,4% in patients where SSI was absent (p = 0,03). There was no statistical significance in hernia occurrence between both genders and among patients with low, normal and high BMI in our cohort of patients. Conclusions Incisional hernia after ostomy reversal is a common late surgical complication. All measurements that reduce SSI at the reversal site are important for lower hernia incidence. Prophylactic mesh implantation at stoma reversal sites may be considered in these patients.