P-P26 Post-laparotomy pain: the Rectus Sheath Pocket technique compared to other analgesic modalities

Background Wound pain is a major cause of morbidity after laparotomy, leading to reduced mobility, poor respiratory effort, and delayed discharge. In our centre, we have developed a safe and effective post-operative analgesia technique that reliably delivers a continuous, stable infusion of local anaesthetic solution into a pocket superficial to the posterior rectus sheath. Methods Sixty-eight adult patients were enrolled in the study. Group A, n = 38 received rectus sheath catheter (RSC) analgesia and Group B, n = 30 received standard post-operative analgesia. The pain score on day 1 and total opioid dosage over the first 72 hours post-operatively were recorded. All patients were recruited from Mater Dei Hospital which is the main acute hospital in Malta. The patients who were recruited consecutively for the study group underwent elective or emergency laparotomies within a pancreatic-biliary firm. For the control group, patients underwent elective or emergency laparotomies under the care of other teams within the same surgical department. Results Group A displayed significantly diminished mean pain scores (2.81±2.26 vs 4.66±2.86 p = 0.003) but no statistically significant reduction in cumulative opiate usage. On further subgroup analysis, patients over 65 years of age with RSC, displayed significantly less overall cumulative opiate usage (10.09±15.71 vs 25.79±32.97, p = 0.005). Few mild complications were recorded; catheter dislodgement (5), entrapment of catheter in wound sutures (1) and a wound hematoma (1) caused upon insertion. Conclusions Although inter-cohort demographics are consistent, case heterogeneity is acknowledged as a weakness of this endeavour. In adult patients, RSC has been demonstrated to be feasible, safe, and effective at diminishing pain scores in the postoperative period, especially so in the elderly population.

Developing a morphomics framework to optimize implant site-specific design parameters for islet macroencapsulation devices

Delivering a clinically impactful cell number is a major design challenge for cell macroencapsulation devices for Type 1 diabetes. It is important to understand the transplant site anatomy to design a device that is practical and that can achieve a sufficient cell dose. We identify the posterior rectus sheath plane as a potential implant site as it is easily accessible, can facilitate longitudinal monitoring of transplants, and can provide nutritive support for cell survival. We have investigated this space using morphomics across a representative patient cohort (642 participants) and have analysed the data in terms of gender, age and BMI. We used a shape optimization process to maximize the volume and identified that elliptical devices achieve a clinically impactful cell dose while meeting device manufacture and delivery requirements. This morphomics framework has the potential to significantly influence the design of future macroencapsulation devices to better suit the needs of patients.

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

VP026 LIRA-TAPE TECHNIQUE. A NEW PROCEDURE FOR RESTORING THE MIDLINE BY MIS IN SUPRAPUBIC AND MIDDLE SIZE MIDLINE HERNIAS

Aim LIRA (Laparoscopic Intracorporeal Rectus Aponeuroplasty) was described in 2018 in order to reduce the tension in the midline as an alternative for Closing the defect (CD) during Laparoscopic Ventral Hernia Repair. TAPE (Transabdominal Partial Extraperitoneal) was described in 2011 in order to repair complex suprapubic hernias to reduce the recurrence rate. We present a case of suprapubic hernia associated to a medium-size midline hernia using LIRA combined with TAPE as a new procedure for abdominal wall reconstruction Material and Methods 50 years old female affected with a M5 W2 hernia associated to a M2-3 W2. (EHS Classification). Preoperative scan was performed. Results 3 Ports (2 of 5 mm, 1 of 12 mm) in the left mid axillary line for LIRA and supraumbilical (10 mm) and right paraumbilical (5mm) to assist TAPE were placed. A peritoneal flap is created to expose de pubic arch and the Coopeŕs Ligament. CD was performed in suprapubic defect using a barbed suture and continued for LIRA procedure in the posterior rectus sheath. An intraabdominal mesh was placed (Polyvinylidene fluoride (PVDF) mesh, Dynamesh (®)-IPOM (FEG Textiltechnik mbH, Aachen, Germany. The mesh overlapped the suprapubic arch and was fixed using helicoidal sutures and covered the whole incision in the midline. Pelvic flap covered partially the mesh. Patient was discharge in 72 h Conclusions Complex hernias close to bones, as suprapubic hernias, can be restored using a minimal invasive approach, even those associated to mid-line defects. LIRA-TAPE is a safe and reproducible association for restoring the midline with a low rate of complications.

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.

OV06 EXTENDING THE INDICATIONS OF TRANSVERSUS ABDOMINIS RELEASE: SUBLAY MESH REPAIR FOR A RARE CASE OF ACQUIRED DIAPHRAGMATIC HERNIA

Aim Acquired diaphragmatic hernia (ADH) is rare and its treatment is challenging. Posterior component separation (PCS) with transversus abdominis release (TAR) is gaining wide acceptance for the repair of complex abdominal hernia, including those located in proximity of the abdominal borders. In this view the central tendon of the diaphragm could be intended as the rooftop border of the peritoneal sac. We describe an original application of TAR for the treatment of an unusual case of ADH. Material and Methods a 54 year-old man was referred to our department for an ADH, following two previous sternotomies for an aortic aneurysm, conditioning respiratory symptoms. A thoraco-abdominal contrast enhanced CT-scan confirmed an anterior left diaphragmatic defect with a transverse diameter of 8.5 cm and a huge sac containing the great omentum and the distal transverse colon, with atelectasis of the inferior lobe of the lung. A subxiphoid M1W2L2 incisional hernia was also detected. The patient underwent a midline xipho-umbilical laparotomy and a repair by partial TAR with posterior rectus sheath release and progressive dissection of the diaphragmatic muscular fibers far beyond the DH. A sublay repair with a large dual layer PVDF mesh was then accomplished. Results Postoperative course was uneventful and no recurrence was recorded at 6 months follow up. Conclusions partial-TAR could be a good option for repair of anteriorly placed ADH, ensuring a stable anatomical repair with an overlap that is usually wider than after laparoscopic IPOM repair. This novel indication confirms the extreme versatility of TAR for the repair of complex ventral hernia

A pragmatic, evidence-based approach to coding for abdominal wall reconstruction

Purpose Ambiguity exists defining abdominal wall reconstruction (AWR) and associated Current Procedural Terminology code usage in the context of ventral hernia repair (VHR), especially with recent adoption of laparoscopic and robotic-assisted AWR techniques. Current guidelines have not accounted for the spectrum of repair complexity and have relied on expert opinion. This study aimed to develop an evidence-based definition and coding algorithm for AWR based on myofascial releases performed. Methods Three vignettes and associated outcomes were evaluated in adult patients who underwent elecive VHR with mesh between 2013 and 2020 in the Abdominal Core Health Quality Collaborative including: (1) no myofascial release (NR), (2) posterior rectus sheath myofascial release (PRS), and (3) PRS with transversus abdominis release or external oblique release (PRS-TA/EO). The primary outcome measure was operative time based on the following categories (min): 0–59, 60–119, 120–179, 180–239, and 240 + ; secondary outcomes included disease severity measures and 30-day postoperative outcomes. Results 15,246 patients were included: 7287(NR), 2425(PRS), and 5534(PRS-TA/EO). Operative time increased based on myofascial releases performed: 180–239 min (p < 0.05): NR(5%), PRS(23%), PRS-TA/EO(28%) and greater than 240 min (p < 0.05): NR (4%), PRS (17%), PRS-TA/EO(44%). A dose–response effect was observed for all secondary outcome measures indicative of three distinct levels of patient complexity and outcomes for each of the three vignettes. Conclusion AWR is defined as VHR including myofascial release. Coding for AWR should reflect the actual effort used to manage these patients. We propose an evidence-based approach to AWR coding that focuses on myofascial release and is inclusive of minimally invasive techniques.

Autologous Posterior Rectus Sheath as a Vascularized Onlay Flap: a Novel Approach to Hiatal Hernia Repair

Introduction Complex and recurrent paraesophageal hernia repairs are a challenge for surgeons due to their high recurrence rates despite the use of various prosthetic and suturing techniques. Methods Here we describe the use of vascularized fascia harvested from the posterior rectus sheath with peritoneum during robotic hiatal hernia repair in two patients with large complex diaphragmatic defects. Results Successful harvesting and onlay of the right posterior rectus sheath based on a falciform vascular pedicle was achieved robotically by rotating and securing the flap to the diaphragmatic hiatus as an onlay flap following cruroplasty of the hiatal defect. Conclusions In patients with difficult to repair large paraesophageal hernias, we demonstrate a promising new technique to restore the dynamic hiatal complex with the tensile strength of autologous vascularized fascia and peritoneum.

Results of a Prospective Cohort Study on Open Rives Technique of the Midline Incisional Hernia: Midline Closure and Mesh Overlap

Background. Rives repair has been traditionally used for large abdominal wall defects with good results on terms of recurrence. However, it is limited by the lateral border of the posterior rectus sheath. The objective of our study was to evaluate recurrence rate, midline closure and mesh overlap in patients operated on elective midline incisional hernia by open Rives retromuscular repair. Methods. This is a prospective observational study of 83 patients who underwent elective open Rives technique between January 2014 and December 2018. Main inclusion criteria were adults with a midline incisional hernia. Recurrence, midline closure and mesh overlap were determined. Results. At a median postoperative follow-up of 32 (5-59) months, 8 cases of recurrence were reported. Patients with recurrence had wider hernia defects (101 ± 52 mm vs 66 ± 36 mm, P = .014) and were repaired with wider meshes (191 ± 93 mm vs 137 ± 68 mm, P = .042). However, although it was not statistically significant, midline closure was lower (38% vs 59%), as well as the overlapping relationship between mesh area and hernia defect area (2.937:1 vs 3.732:1) on patients that developed a recurrence. Conclusions. Rives technique provides good mid-term results in a midline incisional hernia (10% of recurrence at 36 months), including wider hernias in the recurrent cohort. The authors believe that other techniques which allow midline closure and placement of bigger meshes should be considered, especially in those hernias classified as W3 on EuraHS classification (more than 10 cm on width size).

A new minimally invasive technique for the repair of diastasis recti: a pilot study

Background Diastasis recti is an abdominal wall defect that occurs frequently in women during pregnancy. Patients with diastasis can experience lower back pain, uro-gynecological symptoms, and discomfort at the level of the defect. Diastasis recti is diagnosed when the inter-rectus distance is > 2 cm. Several techniques, including both minimally invasive and open access surgical treatment, are available. Abdominoplasty with plication of the anterior rectus sheath is the most commonly used, with the major limitation of requiring a wide skin incision. The new technique we propose is a modification of Costa’s technique that combines Rives–Stoppa principles and minimally invasive access using a surgical stapler to plicate the posterior sheaths of the recti abdominis. Methods It is a fully laparoscopic technique. The pneumoperitoneum is induced from a sovrapubic trocar, placed using an open access technique. The posterior rectus sheath is dissected from the rectus muscle using a blunt dissector to create a virtual cavity. The posterior sheets of the recti muscles are plicated using an endo-stapler. A mesh is then placed in the retromuscular space on top of the posterior sheet without any fixation. Using a clinical questionnaire, we analyzed the outcomes in 74 patients who underwent minimally invasive repair for diastasis of the rectus abdominis sheath. Results Seventy-four patients (9 men and 65 women) were treated using this technique. Follow-up was started two months after surgery. All procedures were conducted successfully. There were no major complications or readmissions. No postoperative infections were reported. There were two recurrences after six months. There was a significant reduction in symptoms. Conclusions This new method is feasible and has achieved promising results, even though a longer follow-up is needed to objectively assess this technique.