P013 HOW TO IMPROVE TREATMENT OF COMPLEX INCISIONAL HERNIAS IN OBESE PATIENTS: A SINGLE-CENTRE STUDY, AN EVALUATION OF LESS-OPEN TECHNIQUE AND FREE-FIXATION TECHNIQUE

Aim Surgery of a complex incisional hernia in an obese patient is a challenging procedure for hernia surgeons. The aim of a new approach is to reduce complications such as pain and wound events, without increasing the number of recurrences. Material and Methods Adults with BMI more than 35 who underwent open, elective operation of a complex incisional hernia (with horizontal diameter more than 12cm) including posterior component separation technique with TAR (transversus abdominis muscle release) and retromuscular synthetic large-pore mesh placement, were identified. Patients were divided into 2 groups: The first group was treated with standard open technique with fixation using interrupted stitches, and the second group was treated with a technique using light hook and no or reduced fixation in the upper and lower pole of the mesh. For post-operative complication evaluation, the Clavien-Dindo classification was used. We have also evaluated an average operation time, length of stay, duration of opioid need. The long-term follow-up was 6 – 48 months. Results There was no significant difference in length of stay, the need of analgetic treatment, and hernia recurrence. Shorter operation time, and lower occurrence of surgical-site infections were reported in the second group, but it was not significant. Conclusions Open posterior component separation technique with TAR using large-pore mesh and no/minimal fixation seems to be a safe and sufficient method of treatment for complex incisional hernias in obese patients. Alternative methods may reduce early complications and pain and do not increase number of recurrences. A larger group of patients and longer follow-up should be needed to improve these findings.

P045 MEDIALIZATION AFTER COMBINED ANTERIOR AND POSTERIOR COMPONENT SEPARATION IN GIANT INCISIONAL HERNIA SURGERY, AN ANATOMICAL STUDY

Aim To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation (ACS, PCS) is often performed. In extreme patients, ACS and PCS may be combined. The aim of this study was to assess the additional medialization after simultaneous ACS and PCS. Material and Methods Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), ACS and PCS, the order in which the component separation techniques (CST) were performed was reversed for the contralateral side. Medialization was measured at three reference points. Results ACS provided most medialization for the anterior rectus sheath, PCS provided most medialization for the posterior rectus sheath. After combined CST total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional PCS after ACS provided 15% to 16%, and additional ACS after PCS provided 32% to 38% of the total medialization after combined CST. For the posterior rectus sheath, additional PCS after ACS provided 50% to 59%, and additional ACS after PCS provided 11% to 17% of the total medialization after combined CST. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization. Conclusions ACS provided most medialization of the anterior rectus sheath and PCS provided most medialization of the posterior rectus sheath. Combined CST provides marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks.

OV14 POSTERIOR COMPONENT SEPARATION FOR A GIANT LUMBAR HERNIA IN A KIDNEY TRANSPLANT PATIENT

Aim Posterior component separation with transversus abdominis release (PCS-TAR) represents a good option for challenging complex ventral hernia repairs. We present a case of PCS-TAR for a giant lumbar hernia in a patient with a transplanted kidney. Material and Methods The patient is a 46 years old man with a Charlson Comorbidity Index of 2 and a BMI of 27.5 kg/m2 who underwent a kidney transplant in 2005 and a subsequent open repair with mesh implantation for an incisional hernia in 2007. Two years later, he experienced a hernia recurrence, but chose conservative management. In 2019, the patient complained of progressively worsening pain and bulky sensation. Due to the size and location of the defect and the massive relaxation of the muscle fibers, open repair with PCS-TAR was indicated. Results In 2019, the patient underwent right-sided PCS-TAR with retromuscular placement of one polyvinylidene fluoride (PVDF) mesh and one biosynthetic mesh. Duration of the procedure was 295 minutes. Two drains were placed, respectively in the subfascial and in the subcutaneous plane. Postoperative course required non-invasive ventilation for respiratory distress, but was otherwise uneventful and he was discharged on postoperative day 8. After 12 months, the patient showed no signs of recurrence. Conclusions PCS-TAR is a versatile technique for the repair of complex ventral hernias, with an acceptable rate of postoperative complications and good long-term outcomes.

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.