Synthetic mesh placement - modality of choice in spontaneous intercostal pleural herniation: a case report

Hernia is defined as protrusion of a viscus or its part from the wall covering it and in some rare cases due to increased intercostal space there is spontaneous herniation of pleura and lung also known as extrathoracic lung hernia. A 48 year gentleman was admitted in our centre for chest wall swelling which has developed spontaneously 1 year back, painless, with cough impulse, further investigations like chest x-ray revealed nothing , subsequently CT thorax showed intercostal pleural hernia. He underwent surgery which diagnosed it as a case of intercostal pleural hernia having defect between 8th and 9th rib. Subsequently primary repair of defect was done with placement of monofilament mesh over it and then approximation of intercostal space was done with monofilament suture placed over 8th and 9th ribs. Post operatively patient had no complications and no recurrence of hernia. Spontaneous pleural herniation is a usually caused by coughing, heavy weight lifting, weakness of thoracic muscles by smoking, obesity etc. Ideal management is to treat the aetiology along with repair of the defect to prevent recurrence. In the present case the hernia developed after a bout of cough due to increased intercostal space between 8th and 9th ribs and also due to obesity leading to weak musculature. Intercostal pleural hernia repair can be achieved by primary repair of defect but it is advisable to use synthetic materials such as knitted monofilament polypropylene (Marlex) mesh to provide addition support to prevent recurrence.

Non-closure of the Free Peritoneal Flap During Laparoscopic Hernia Repair of Lower Abdominal Marginal Hernia: A Retrospective Analysis

Background: During lower abdominal marginal hernia repair, the peritoneal flap is routinely freed to facilitate mesh placement and closed to conclude the procedure. This procedure is generally called trans-abdominal partial extra-peritoneal (TAPE). However, the necessity of closing the free peritoneal flap is still controversial. This study aimed to investigate the safety and feasibility of leaving the free peritoneal flap in-situ.Methods: A retrospective review was conducted on 68 patients (16 male, 52 female) who underwent laparoscopic hernia repair between June 2014 and March 2021. Patients were diagnosed as the lower abdominal hernia and all required freeing the peritoneal flap during the operation. Patients were divided into 2 groups: one group was TAPE group with the closed free peritoneal flap, another group left the free peritoneal flap unclosed. Analyses were performed to compare both intraoperative parameters and postoperative complications.Results: There were no significant differences in demographic, comorbidity, hernia characteristics and ASA classification. The intra-operative bleeding volume, visceral injury, hospital stay, urinary retention, visual analog scale (VAS) score, dysuria, intestinal obstruction, surgical site infection, mesh infection, recurrence rate and hospital stay were similar among the two groups. Mean operative time of the flap closing procedure was higher than for patients with the free peritoneal flap left in-situ (p = 0.002). Comparisons of postoperative complications showed flap closure resulted in a higher incidence of seroma formation (p = 0.005).Conclusion: Providing a barrier-coated mesh is used during laparoscopic lower abdominal marginal hernia repair, it is safe to leave the free peritoneal flap in-situ and this approach may prevent the occurrence of seromas.

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.

Prevention of Incisional Hernia in Ovarian Cancer Patients Undergoing Midline Laparotomy

BACKGROUND: Incisional hernias (IH) are a frequent complication of midline laparotomies in abdominal surgery. This study was conducted in order to determine the efficacy of mesh placement and assess the optimal fascia closure technique to reduce the IH rate in patients surgically treated after being diagnosed with malignant or borderline ovarian tumors.METHODS: Retrospective data from patients undergoing midline laparotomy for borderline or ovarian cancer in Hospital del Mar, Barcelona, from January 2008 to December 2019 were collected. Patient demographic, preoperative and intraoperative characteristics and risk factors for hernia were reported. The incidence of IH between groups (mesh and non-mesh) and the technique used in fascial closure for each patient (small bites technique vs large tissue bites) was reported. RESULTS: In total, 133 patients with available data for follow-up were included. After clinical and radiological examination, 25 (18.79%) of them showed IH. 18 of 61(29.5%) patients in non-mesh group developed IH, compared with 7 of 72 (9.7%) in mesh group (OR 0.25, 95% CI 0.09-0.66, p<0.005). Patients of large tissue bites group showed higher prevalence of IH compared with small bites technique group without statistical significance (OR 0.46, 95% CI 0.17-1.24, p=0.119). The combination of mesh reinforcement and small bites technique for fascial closure significantly reduce IH risk (p=0.021). CONCLUSION: Incidence of IH is high in patients undergoing midline laparotomy for ovarian cancer or borderline ovarian tumor. The addition of a prophylactic mesh and use of small bites technique may reduce the incidence of IH and potentially minimize the social impact and costs of this complication.

P138 PREPERITONEAL ENDOSCOPIC GROIN HERNIA SURGERY - REASSESSMENT OF TOPOGRAPHIC ANATOMY AS A BASIS FOR STANDARDIZED DESCRIPTION OF SURGICAL STEPS

Aim Fascial groin anatomy remains a conundrum. In particular, a clear anatomical allocation of the correct extraperitoneal dissection planes and spaces in total extraperitoneal endoscopic hernia surgery (TEP) has not yet agreed upon. The differing anatomical concepts are reflected by the variability of surgical approaches, the considerably long learning curves and subsequent complications. Thus, the aim of this study was to reassess the topographic anatomy of the groin region providing a basis to standardize the surgical steps of TEP according to clearly defined anatomical landmarks. Material and Methods Video analysis of intraoperative surgical anatomy of groin hernia patients was correlated with the findings retrieved by macroscopic anatomical studies. The groin region of formalin fixed body donors was subjected to a stepwise dissection exposing the fascial system of the abdominal wall layer-by-layer and via different angles. Selected areas of interest were processed for histological study. Surgically relevant anatomical landmarks were defined and termed according to the most appropriate anatomical nomenclature. Results The essential surgical dissection steps during TEP could be related to specific anatomical landmarks extending within the extraperitoneal space of the ventral and dorsolateral abdominal wall. The definition of fascial structures and interfaces and the identification of structures at risk allowed the identification of correct dissection planes for mesh placement. Conclusions Our study helps to clarify the definition and nomenclature of anatomical key structures required for a standardized description of TEP in a simplified model. The data may contribute to reduce complications and improve surgical teaching and training.

P049 SAFETY AND EFFICACY OF ABSORBABLE AND NON-ABSORBABLE FIXATION SYSTEMS FOR INTRAPERITONEAL MESH FIXATION: AN EXPERIMENTAL STUDY IN SWINE

Aim Choice of the best fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of this study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation. Material and Methods Fourteen Landrace swine were utilized and the experiment included two stages. Initially, four pieces of polypropylene mesh with hydrogel barrier coating1 were fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. Each mesh was anchored with a different tack device between titanium2, steel3 or absorbable (4,5) fasteners. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy. The primary endpoint was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks. Results Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Steel tacks had higher peel strength when compared to titanium and absorbable fasteners. No significant differences were noted regarding the secondary endpoints. Conclusions Steel fasteners provided higher peel strength that the other devices in this swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

P127 ROBOTIC TRANSABDOMINAL RETRO-RECTUS HERNIA REPAIR VS. LAPAROSCOPIC INTRAPERITONEAL ONLAY MESH REPAIR: IMPROVING POSTOPERATIVE OUTCOMES

Aim “The optimal repair technique for small and medium-sized ventral hernias in obese patients remains unknown. We aimed to evaluate results after robotic-assisted laparoscopic transabdominal repair with retro-rectus mesh placement (rTARUP) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM).” Material and Methods “Retrospective cohort study of consecutive patients undergoing rTARUP or IPOM repair for small or medium-sized primary ventral and incisional hernias. The primary outcome was postoperative need for transverse abdominis plane (TAP) block or epidural catheter, and secondary outcomes were 30-day complications, and length of stay. All patients underwent elective surgery and were followed for 30 days postoperatively.” Results “A total of 27 patients (rTARUP) and 32 (IPOM) were included. Patients in the two groups were comparable in terms of age, sex, comorbidities, smoking status, body mass index (BMI), and type of hernia. The median BMI was 32.4 kg/m2 and the fascial defect area was comparable (rTARUP median 16.8 cm2 vs. IPOM 11.7 cm2, P = 0.303). The duration of surgery was longer in the rTARUP group (median 117.2 min. vs. 84.4, P = 0.003), whereas the postoperative need for TAP block or epidural analgesics was less in the rTARUP group compared with IPOM (n = 14 vs. n = 1, P = 0.002). There were no severe complications or reoperations in the two groups. The length of stay was shorter in the rTARUP group (median 0 vs. 1 days, P &lt; 0.001).” Conclusions “rTARUP was associated with reduced postoperative analgesic requirement and shorter length of stay compared with laparoscopic IPOM.”

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.

P083 PARASTOMAL HERNIA REPAIR - EXPERIENCES WITH THE MODIFIED RETROMUSCULAR SUGARBAKER TECHNIQUE

Aim Parastomal hernias are complex findings with a high recurrence rate. Various methods were described for surgical repair. A new method for the treatment of parastomal hernias with extraperitoneal mesh placement was published in 2016 (Pauli et al.). Recently, open retromuscular repair has been shown to be safe, effective and durable (Beffa et al. 2017). Still, there are concerns regarding mesh related complications (Tastaldi et al. 2017). Material and Methods All patients who underwent an open or laparoscopic modified retromuscular Sugarbaker parastomal hernia repair at our institution were identified. We describe the patient characteristics, operative details, perioperative results and the follow-up. Results Between January 2018 to May 2021 14 patients received surgical repair for parastomal hernia at our institution. Eight of these patients received retromuscular extraperitoneal mesh placement (4 open, 4 laparoscopic) in the aforementioned technique. The median age was 72 years (65 – 85) and the median BMI was 31 kg/m² (26 – 34). Six patients had a urostomy and two had a colostomy. One patient had a recurrent parastomal hernia after previous intraabdominal mesh repair. The median operating time was 223 minutes (144 – 425). Median Mesh size was 300 cm² (225 – 750). Two minor complications (Clavien-Dindo Classification Grade II) demanding pharmacological treatment. The median hospital stay was 8 days (4 – 17). Median follow up was 17 month (range 1 – 26). Recurrence rate was 25 %. Conclusions The modified retromuscular sugerbaker technique seems to be safe and feasible as shown by our data. Due to the extraperitoneal mesh position, we see fundamental methodological advantages. Further studies are necessary for long-term results.