P015 ABDOMINAL WALL PREPARATION PRECEDING COMPLEX ABDOMINAL WALL RECONSTRUCTION (CAWR) - SINGLE CENTER INITIAL EXPERIENCES UTILIZING BOTULINUM TOXIN A (BTA) ACCOMPANIED IN SELECTED PATIENTS BY PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM (PPP)

Aim Complex ventral hernia (CVH) treatment due to large abdominal wall defects or loss of domain is challenging. BTA-injection in lateral abdominal wall causing flaccid paralysis and elongation, so called chemical component separation (CCS), might facilitate closure of large fascial defects. Combining preoperative progressive pneumoperitoneum might help restore abdominal content in severe loss of domain situations. We studied the results after CAWR following abdominal wall preparation with BTA and possible PPP. Primary aim was to report fascial defect closure rate without need for surgical component separation. Material and Methods All electively operated patients to date that were treated preoperatively with BTA, including all patients treated with PPP. Results Hospital index patient received preoperative BTA in January 2018. Since then, altogether 42 patients underwent CCS prior to CAWR. Average patient suffered from obesity (mean BMI 31), 30% had diabetes, and a third were active smokers. Mean hernia defect area exceeded 200 cm2. All operations were mesh repairs. Surgical approach was mostly (88%) open retromuscular. Abdominal wall reconstruction via fascial closure was achieved in 93% of cases with only 21% needing surgical component separation. Preoperative morbidity was common in patients undergoing PPP. Around 40% of all patients had postoperative complications, half of which were surgical complications. One patient died of a yet unknown cause on the third postoperative day. There were no recurrences within median 15 months follow-up. Conclusions Restoring abdominal wall continuity without frequent need for surgical component separation seems likely in CVH following CCS.

OV02 COMPLEX PARASTOMAL HERNIA REPAIR WITH MESH FISTULA AND MESH INFECTION

Aim Parastomal hernias of any size can be difficult to manage and greatly affect a patient’s quality of life, however, they can be even more problematic when associated with loss of domain and infection. The aim of our video was to demonstrate open repair of a massive parastomal hernia complicated by loss of domain, mesh fistula, and mesh infection. Material and Methods Images and footage from clinic and the operative procedure were included. Results A 51-year-old female with a history of prior APR followed by failed ventral and parastomal hernia repairs presented with a massive parastomal hernia that was significantly impacting her and her family’s quality of life. Due to her hernia, she had become immobile and was bed bound. Furthermore, the hernia had caused significant chronic constipation secondary to colonic dysmotility. The patient also had loss of domain, and her hernia appeared to be complicated by a chronic mesh infection with a draining sinus. She underwent pre-operative bilateral botulinum toxin A injection in the oblique abdominal musculature. She then underwent open preperitoneal parastomal hernia repair with biologic mesh, excision of prior mesh, primary fistula repair, total abdominal colectomy, and end ileostomy. The patient tolerated the procedure well without complications and has continued to do well in follow-up. She has had great improvement in her quality of life. Conclusions In this patient with a massive parastomal hernia complicated by loss of domain, mesh fistula, and mesh infection, we demonstrate a successful open preperitoneal repair following pre-operative BTA injection.

OV16 MASSIVE COMPLEX INGUINAL HERNIA

Aim Massive complex inguinal hernias can be exceptionally difficult to repair, especially when they are associated with loss of domain (LOD). We aim to demonstrate an open preperitoneal approach to a complex massive inguinal hernia extending into the scrotum with severe LOD. Material and Methods Footage from clinic, diagnostic imaging, and all operative procedures was included. This included botulinum toxin A (BTA) injection, diagnostic laparoscopy and placement of a peritoneal catheter, outpatient pre-operative progressive pneumoperitoneum (PPP), and the preperitoneal hernia repair. Results A 53-year-old male construction worker with a known inguinal hernia presented with worsening groin and scrotal pain, associated with fever. CT imaging showed an abscess secondary to perforated diverticulitis within his massive inguinal hernia, as well as massive loss of domain with almost all small and large intestine within the hernia. He was treated with antibiotics and percutaneous drainage in preparation for surgery. He received pre-operative bilateral BTA injection in the oblique abdominal musculature. Subsequently, he underwent diagnostic laparoscopy and peritoneal catheter placement. He received 2 weeks of outpatient PPP. He then underwent open inguinal hernia repair with left orchiectomy and total abdominal colectomy. The hernia was repaired with a biologic mesh placed in the pre-peritoneal plane. The patient recovered very well and had no wound complications post-operatively. He has since followed up in clinic multiple times with no recurrence and excellent cosmetic results. Conclusions In this patient with a complex massive inguinal hernia and loss of domain, we demonstrate a successful open preperitoneal repair following pre-operative BTA injection and PPP.

P009 BEYOND TANAKA INDEX: PREOPERATIVE ASSESSMENT WITH 3D TECHNOLOGY IN LARGE HERNIAS WITH LOSS OF DOMAIN

Aim “Demonstrate step by step the planning that was carried out using 3D technology in pre-surgical assessment for complex hernia.” Material and Methods “57-year-old female, surgical record of laparoscopic uterine myomectomy 20 years ago, has an eventration with loss of domain on the left flank and a giant uterine myoma. A multidisciplinary assessment was carried out for surgical decision, myomectomy was rejected. Presurgical preparation was decided with progressive pneumoperitoneum (PPP) technique (1 week before surgery) associated with botulinum toxin (4 weeks before surgery). The patient specific volumes of the abdominal cavity and the eventration were measured with 3D technology resulting in a volume ratio (VR) of 34% pre-PPP, VR post-PPP and botulinum toxin was 9,8%. We compared these results to Tanaka index and we found a significant difference between the two techniques.” Results “During surgical intervention, multiple tumors were evidenced in the hernia content, distal ileum, cecum and omentum, peroperative pathological anatomy reported leiomyomas. An ileocecal resection+Omentectomy+TAR was performed. Patient was discharged on the 5th day without incidents. A definitive diagnosis of Diffuse Peritoneal Leiomyomatosis was made.” Conclusions “3D technology might represent a better tool to calculate intraabdominal and hernia volume, providing greater safety for the patient and the surgeon to avoid compartment syndrome. We found a significant difference between volumes measurements between Tanaka index and 3D technology. 3D technology gives us an unprecedented perspective for surgical planning in complex abdominal wall surgery The use of PPP and botulinum toxin is a safe and reproducible technique for hernia with loss of domain.”

P023 MANAGEMENT OF MASSIVE INCISIONAL HERNIA WITH LOSS OF DOMAIN

Aim Large incisional hernia treatment is challenging for surgeons especially when there is loss of domain. Its management require an appropiate preoperative optimization of the patient. We present a complex case that provides an exhaustive review of different measures in order to treat this type of hernias. Material and Methods A 61-year-old, smoker and diabetic patient consulted because of a large ventral hernia. He underwent an umbilical hernia surgery which recurred three more times. The patient had a M1-M5 W3 hernia with active suppuration through fistulous orifices. The abdominal wall planning CT scan showed a large eventration with 23 cm of transverse defect diameter and a Tanaka index of 92%. Results The patient received support to quit smoking and he lost weight due to an intragastric balloon. Botulinum toxin was administered six weeks before surgical intervention. An andominal pneumeperitoneum catheter was placed, reaching 12.400 liters of ambient air insufflated during 13 days. Finally, surgery was performed, finding a 27 x 35 cm wall defect that required the performance of: After these maneuvers, the posterior abdominal wall could be completely closed. A double preperitoneal mesh (BioA and polypropylene) was placed. After 16 days, he was discharged without mayor complications. Conclusions Loss of domain hernias are a complex entity which requires a multidisciplinary approach and abdominal wall experienced surgeons since it may require extreme measures.

Complex Incisional Hernia – Easy To Diagnose But What To Do After?

Introduction. Loss of domain represents a defect in abdominal wall or loss of continuity of fascial closure, with more than 20% of the peritoneal cavity content under the skin in a serous sac, where the reconstruction involves additional reconstructive techniques. Clinical Case. A 63-year-old active smoker with multiple comorbidities such as COPD severe form with the need for oxygen at home (may be an absolute contraindication) and surgical history of open umbilical hernia repair with a rapid development of loss of domain hernia (2 weeks after surgery) was prepared preoperatively with Botulinum Toxin type A and Preoperative Progressive Pneumoperitoneum. Discussion. Despite comorbidities, by optimizing the abdominal wall with Botulinum Toxin type A and Preoperative Progressive Pneumoperitoneum with the intraoperative use of the Rives-Stoppa technique or posterior separation of components, Abdominal Wall Strength Score improves significantly in a short time, with quick socio-economic reintegration and low-rate of complications. Conclusions. By preoperative preparation, with augmentation techniques of the abdominal wall, thus, even the barriers given by comorbidities (absolute contraindications) are overcame, with low postoperative risks, offering the patient a normal quality of life.

Repair of giant inguino-scrotal hernia with loss of domain using minimally invasive anterior component separation technique combined with Lichtenstein tension-free mesh hernioplasty

Inguinal hernia repairs are most commonly performed surgical procedures across the world. Lichtenstein's tension free technique of open hernioplasty is the gold standard technique, while laparoscopic techniques gained popularity over recent decade. Giant inguinal hernias are rare. Giant inguinal hernia extends below the midpoint of the inner thigh, in the standing position. These are long standing conditions and at presentation years of herniation or even decades. We report a patient of 65 years of age presented with type-II left sided giant inguinoscrotal hernia from last 10 years with loss of domain. Contrast enhanced computed tomography (CECT) revealed, omentum and ileal loops with mesentry as contained in hernia sac, which was repaired by minimally invasive anterior component separation technique to increase the intra-abdominal volume followed by omentectomy and Lichtenstein mesh hernioplasty without any complications. He recovered uneventfully. Surgical management of giant inguinal hernia is significantly more challenging and unusual because of ‘loss of domain’ and returning herniated viscera into the empty abdominal cavity forcefully can lead to high intra-abdominal pressure, recurrence or abdominal compartment syndrome. There are several repair techniques in literatures such as resection of contents and increased intra-abdominal volume increasing procedures but there is no standard protocol or surgical procedure for the management of giant hernias. We describe a technique which is relatively simple, less expensive and less invasive used for type II unilateral giant inguinoscrotal hernia with loss of domain in patient with co-morbidities.