Ultrasound estimated subcutaneous and visceral adipose tissue thicknesses and risk of pre-eclampsia

Early identification of high-risk pregnancies enables identification of those who would benefit from aspirin prophylaxis and increased surveillance for pre-eclampsia. A high body mass index (BMI) is a well-known predictor for pre-eclampsia. However, if abdominal adipose tissue distribution is associated with pre-eclampsia is limited investigated. Subcutaneous adipose tissue (SAT) thickness and visceral adipose tissue (VAT) thickness were measured by ultrasound on 3777 women at around 18 gestational weeks. SAT thickness was measured from the skin to linea alba and VAT from linea alba to the anterior aortic wall. The risk of developing pre-eclampsia (de novo hypertension at ≥ 20 gestational weeks in combination with proteinuria) was evaluated by logistic regression and expressed as odds ratio (OR) with 95% confidence intervals (CI). The risk of pre-eclampsia increased by 79% for every cm in SAT thickness (OR 1.79; 95% CI 1.48–2.17) and by 23% for every cm VAT thickness (OR 1.23; 95% CI 1.11–1.35). After adjustment for maternal age, parity, BMI, smoking and country of birth, the association between SAT thickness and pre-eclampsia remained (AOR 1.35; 95% CI 1.02–1.79). Greater SAT thickness measured with second trimester ultrasound is associated with increased risk of developing pre-eclampsia. The measurement may improve prediction models for pre-eclampsia.

P037 TOTALLY ENDOSCOPIC SUBLAY REPAIR FOR DIASTASIS RECTI AND CONCOMITANT MIDLINE HERNIA: FIRST CASE VIDEO-REPORT

Aim We describe in detail the step by step technique of the first case of TES repair at our institution. Methods We selected the case of a M2W3L3 hernia associated to xipho-umbilical diastasis recti in a young woman symptomatic for a progressively worsening back pain and local bulky sensation. Results The intervention is started directly with a suprapubic transverse incision of 2.5 cm and a circumferential, atraumatic retraction is inserted after a small incision of the anterior rectus sheath. Blunt dissection is further continued through this access by luxating the underlying rectus muscles to separate the preperitoneal space below the arcuate line. The pneumo-preperitoneum is then inducted through this port. Laparoscopic dissection allows for enlargement of the avascular space laterally and then two 5-mm trocars are placed on the bilateral aspects of rectus muscles. By means of a lap bipolar dissector the edge of posterior rectus sheath are incised from the arcuate line following the diastasis laterally up to the subxiphoid space. The Rives plane is recovered without opening of the linea alba. After reduction of the M2 hernia both the posterior sheath and the diastatic anterior fascia are sutured with a running long-resorbable 2/0 barbed suture. Polyvinylidene fluoride (PVDF) mesh fixed with the use of an hystoacrilic glue. Conclusion Minimally invasive extraperitoneal repair of small/medium hernia defects of the linea alba is gaining wide acceptance. Concomitant presence of rectum diastasis recti seems to be the ideal indication to approach the learning curve of such a technically demanding procedure

P094 DIASTASIS POST-PREGNANCY PROGRAM

Aim This study aims to summarize our knowledge in rectus abdominis diastasis based on the experience collected by the multidisciplinary program. Material and Methods Retrospective analysis of a prospective database. The diastasis post-pregnancy program is an interdisciplinary protocol that aims to restore the anatomical and functional structure of the abdominal wall after the degenerative process of pregnancy. Used a systematic multidisciplinary evaluation that included an abdominal walls surgeon, plastic surgeon, physiotherapist, and radiologist. Following the findings, we propose a classification, adapting the specific treatment according to the degree of the patient's condition. Grade I only performed physiotherapy; Grade II: started physiotherapy plan, with associated surgical treatment due to lack of response; Grade III underwent surgery as the first treatment in addition to physiotherapy protocol. Endoscopic-assisted linea alba reconstruction plus mesh have using to repair midline hernias in association with diastasis. Results From January 2017 and June 2019, 1085 patients completed the program. Clinical classification: Grade I: 760 patients (70 %) and Grade II: 248 patients (64%) performed physiotherapy as first-line treatment, with associated surgical treatment being necessary for 89 patients (36%); Grade III: 77 patients (7%) underwent surgery as first-line treatment, associated with physiotherapy postoperative protocol. Postoperative complications were: 31 seromas(14%) , 11 omphalitis (5%), 5 hematoma (2%) 1 (0.44%) required surgical dressing. Mc Gill and Us Check-up post-treatment test showed improvement in 77 % of patients. Please insert your text here. Conclusions Evaluation and treatment, in post-pregnant patients, using a multidisciplinary approach concept showed good initial results with important improvement anatomical, functional, clinical, and aesthetic.

P139 LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL REPAIR FOR SMALL AND MEDIUM PRIMARY UMBILICAL AND MIDLINE HERNIAS

Aim Complications of open mesh repair for primary umbilical and midline hernias (PUMH) may lead to significant re-admissions and follow-up costs. Although laparoscopic intraperitoneal onlay mesh repair reduces infection rates, especially in overweight patients, it’s controversial in these hernias, mainly due to potential adhesions’ formation. Laparoscopic transabdominal preperitoneal technique (lap-TAPP) may address these issues, as it combines advantages of both open and laparoscopic approaches. The aim of this study is to present the initial results of lap-TAPP for PUMH in regard to its feasibility and complication rates. Material and Methods We evaluated 25 consecutive cases of lap-TAPP repair for PUMH. Patients’s characteristics, intraoperative findings, and postoperative complications after 30-days follow-up were analyzed. Results 21 male and 4 female patients were included in analysis (mean BMI 29.8 kg/m2). Surgery time was 82 minutes (55-120). We found 20 umbilical and 11 epigastric linea alba hernias. Mesh size was 144cm2 (120-225); mean hernia defect width was 25mm (10-40). In 9 patients (36%) the peritoneal rents were created which were easily closed with sutures. All patients were discharged on 1 POD with no complications. After 30-days we found no recurrences or bulging, no pain complaints. We found one subcutaneous small hematoma with no need for intervention. Conclusions Laparoscopic TAPP for small and medium PUMH is a safe and feasible technique with low complication rate. However, this method is technically demanding and time consuming while performed with laparoscopic approach as it requires precise and subtle plane dissection, and non-ergonomic closure hernia defect.

OV09 ROBOTIC REPAIR OF SUBXIPHOID INCISIONAL HERNIA POST CABG

Aim A median sternotomy that extends toward the epigastric area can weaken the upper abdominal wall and result in the development of subxiphoid incisional hernia. We aim to assess the efficacy and the feasibility of repair of subxiphoid incisional hernia post CABG robotically. In this video; we will also review the surgical technique and the steps for robotic repair of subxiphoid incisional hernia Material and Methods 57-year-old female presented with subxiphoid swelling post CABG in 2019. Her surgery was complicated with sternotomy wound infection with VAC dressing application and ARDS with prolonged intubation. She had 5x7 cm hernia defect that showed on the CT thorax along with sternal wound dehiscence. She underwent robotic repair of her hernia with phasix mesh and recovered well after surgery. Results The subxiphoid hernia is known for its repair complexities and high recurrence rate because the subxiphoid area is a complex structure consisting of boney structures, the rectus abdominis muscles, linea alba, and the diaphragm. The Da Vinci platform allows for accessing hard-to reach area with enhanced precision in dissection and superior dexterity compared to laparoscopy. The Robotic platform allows for manipulation of the camera to assess and operate on the abdominal wall with ease as compared to laparoscopy. Conclusions robotic repair of subxiphoid incisional hernia with mesh is safe and effective method of repair. There are no short-term or long- term side effects of the procedure with no recurrence at 6 months follow up.

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> 60 years old, Body Mass Index > 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.

P076 DIFFERENT SURGICAL APPROACH IN DIASTASIS RECTI REPAIR: IMPORTANCE OF AN OVERALL VIEW OF THE DISEASE

Aim Diastasis Recti (DR) is characterized by a defect of the linea alba sometimes associated with midline hernias, and frequent lipocutaneous excess. We present our experience in the treatment of diastasis recti with Inter Recti Distance (IRD) > 50mm -with or without umbilical hernia- by 3 different approaches. Material and Methods From January 2018 to February 2020, 104 patients were referred to our unit for clinical and radiological diagnosis of DR with IRD > 50 mm. Three different surgical approaches were used, based on presence of lipocoutaneous excess: laparoabdominoplasty, laparominiabdominoplasty and minimally-invasive/endoscopic with Totally Sublay Anterior Repair (TESAR) approach. Results We performed 28 TESAR (29.8%), 44 laparoabdominoplasties (42.3%) and 32 laparominiabdominoplasties (30.8%). Overall complication rate was 26% (27 patients). In 3 (2.9%) cases major surgical complications (Clavien-Dindo 3-4) occurred, all for open operations. Minor complications (Clavien-Dindo 1-2) included: 13 cutaneous ischemia, 10 small muscular hematomas and 1 subcutaneous seroma. The overall median post-operative stay was 3 days (range 2 – 14 days), and 3, 4 and 3 days for TESAR, laparoabdominoplasty and laparominiabdominoplasty groups, respectively. No recurrence registered to date. Conclusions Our experience shows the importance of an overall view of the functional and cosmetic impairment created by the DR. The surgeon must obtain an optimal functional outcome also aiming for the best cosmetic result. Therefore different approaches have to be considered, tailored to the clinical, instrumental and psychological aspects of the disease. The complication rate, while in line with the literature, emphasize how in this type of operation the critical issues of functional as well as morphological surgery coexist.

P068 ROBOTIC REPAIR OF VENTRAL AND INCISIONAL HERNIAS: A STUDY ON 118 PATIENTS OPERATED BY RV-TAPP AND R-RIVES

Aim The purpose of this study is to compare the results of robotic ventral TAPP and robotic retrorectus repair for ventral and incisional hernias. Material and Methods The results of 118 consecutive rv-TAPP (88) and r-Rives (30) surgeries are presented. The study was approved by the ethics committee (Ref. No. 2019-02046). Primary ventral hernias were treated mainly by rv-TAPP approach, incisional hernias by r-Rives Technique. Patients were followed up six weeks postoperatively. Results In every third patient, an additional finding at the linea alba was found. Patients in the r-Rives group were significantly older (p = 0.001). Hernia gaps were significantly larger and meshes were significantly larger in the r-Rives group (p < 0.001). The ratio of mesh area to hernia gap area was comparable in both groups (p = 0.142). OR time was significantly shorter for rv-TAPP (82min) than r-Rives (109min). Hospital stay was shorter in the rv-TAPP group than in the r-Rives group (1.5 vs. 2.7 days, respectively) (p < 0.001). There was a significant clustering of type II seromas in the r-Rives group (p < 0.001), however, the total number of seromas was comparable. Conclusions rv-TAPP and r-Rives have the advantages of minimally invasive procedures (low complication rate) and most of the advantages of open procedures (morphological reconstruction). Both techniques allow consistent extraperitonealization of meshes. Umbilical and epigastric hernias (<4cm) are treated as rv-TAPP; incisional hernias, large hernia gaps (4-7cm), as well as in case of planned suturing of the linea alba, the r-Rives is indicated. Concomitant hernia gaps of the linea alba are also treated. Both procedures have few complications and are suitable for residents training.

P054 REDUCTION OF FAILURE RATES AFTER INCISIONAL HERNIA REPAIR BY ADDING A PROPHYLACTIC MESH

Aim “Can a mesh reduce failure rates after closure of a hernia defect?” Material and Methods “Porcine abdominal walls and bovine flanks were used as model tissues. After preparation, a 15 cm long incision was placed in the linea alba of the porcine abdominal wall. An additional round 5 cm defect was punched in the middle of the incision. The bovine flank was prepared in a similar manner. The incisions with the defects were closed with running sutures in a small stitch, small bite technique. Monomax® 2-0 sutures were used with suture to wound lengths above 4:1. Dynamesh® CiCAT meshes of three different sizes were placed in the sublay position. The mesh-tissue compounds were investigated on our self-built hydraulic bench test simulating coughs. Dynamic intermitted strain (DIS) was repeatedly delivered with impacts around 210 mmHg. Each of ten preparation was loaded 425 times by the pressure peaks.” Results “Small stitch, small bite sutures using 2-0 Monomax® with a suture-incision-ratio of 4.5:1 can provide a durable defect closure. Under other conditions, suture lines can reopen. A mesh reduces the recurrence of incisional hernia depending on the mesh size.” Conclusions “An additional DIS-class A mesh in sublay position can provide sufficient support for a suture closing the defect of the abdominal wall. It can prevent a tear-out of the suture from the tissue. On average, a mesh-augmented defect closure reduces the recurrence rate of incisional hernia.”